Continue or quit? -- Recommendations for repeated controlled ovarian stimulation therapy

Continue or quit? -- Recommendations for repeated controlled ovarian stimulation therapy | 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 Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Continue or quit? -- Recommendations for repeated controlled ovarian stimulation therapy Lin Qi, Shiming Wang, Yaping Liu, Xiaoli Chen, Ningning Wang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2189441/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: It is ambiguous whether the multiple COS with supraphysiologic hormonal doses impact ovarian reserve functions or pregnancy outcomes. Furthermore, relevant retrospective studies are relatively scarce, chiefly in the last century, and ART techniques have seen innovation and improvement in the previous 20 years. Methods: The retrospective study included 45,555 IVF/ICSI fresh cycles enrolled between January 2015 and March 2021 were segregated into 5 different cycle cohorts. The participants were retrospectively grouped according to the number of repeated cycles. The primary observables symbolizing ovarian reserve function were antral follicle count (AFC) and anti-Müllerian hormone (AMH). We analyzed clinical pregnancy rate (CPR), live birth rates (LBR), and early miscarriage rate (EMR) to explore clinical pregnancy outcomes. Statistical methods were used for intra-group self-control comparisons, between-group comparisons, and logistic regression analysis. Result(s): Among the ovarian reserve function indicators, the AMH, AFC, basal FSH and basal LH exhibit no difference between groups ( P > 0.05). In different populations, there was a natural dropout trend for CPR (r = - 0.922, P = 0.026) and LBR (r = - 0.920, P = 0.027) with increasing number of population repetitions, while EMR displayed an increasing trend (r = 0.957, P = 0.011). All differences between groups were statistically significant after logistic regression analysis. Intra-group analysis within same population revealed that, Cycle 2 in Group B (aOR = 8.29; 95% CI, 6.80-10.12; P = 0.000), Cycle 3 in Group C (aOR = 6.05; 95% CI, 3.28-11.15; P = 0.000) and Cycle 4 in Group D (aOR = 20.46; 95% CI, 3.05-137.24; P = 0.002) had the highest CPR within each group; Cycle 2 in Group B and Cycle 3 in Group C had the highest LBR and lowest EMR within each group, and the differences did not reached statistical significance in the remaining groups. Conclusion(s): Repeated COS ( ≤ 5 times) does not disrupt ovarian reserve function. A raise in cycle number significantly increases CPR in the cohort of ≤ 4 repeated cycles, improves LBR, and reduces EMR in cohorts with ≤ 3 repeated cycles. Hence, patients are not advised to undergo ≥ 5 COS cycles. Assisted reproduction repeated COS COS-IVF/ICSI ovarian reserve IVF/ICSI outcome Figures Figure 1 Figure 2 Figure 3 Background Assisted reproductive technology (ART), especially in-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI), has been fleetly evolved to aid infertile couples in achieving a pregnancy. The artificial induction of superovulation by gonadotropin injection, known as controlled ovarian stimulation (COS), is a necessary step in in-vitro fertilization-embryo transfer (IVF-ET). However, it is ambiguous whether the ovarian stimulation with supraphysiologic hormonal doses impacts ovarian functions or pregnancy outcomes. Moreover, most infertile women require multiple COS to increase the chances of clinical pregnancy [ 1 ]. Information on the health effects of multiple COS in infertile women is scarce and needs a comprehensive debate over the existing gaps. Therefore, further thought and extensive research are required to analyze the effect of repeated COS on the health of infertile women. The Ovarian reserve function symbolizes a woman's fertility potential. Some studies have sought to clarify that high doses of exogenous gonadotropins may have depleted follicular reserve at an accelerated rate [ 2 ]. It has been reported that repeated COS does not affect ovarian reserve function and clinical pregnancy rates (CPR) in the first three cycles [ 1 ]. However, repetitive ovarian stimulation resulted in ovarian oxidative stress damage, mitochondrial DNA mutations, the heightened proportion of oocyte spindle defects, and reduced oocyte quality in mice [ 3 , 4 ]. Martin-Johnston et al. [ 5 ] have demonstrated that CPR tends to decline with increasing cycle number, especially after the third cycle. Conversely, Prior publication has queried a conflicting result that repeated COS significantly increases the CPR [ 6 ]. Thus, studies exploring the impact of repeat COS on ovarian reserve function and pregnancy outcome have yielded conflicting or inconclusive results. Furthermore, relevant retrospective studies are relatively scarce, chiefly in the last century, and ART techniques have seen innovation and improvement in the previous 20 years. Consequently, a large-scale updated article investigating the effects of repeated COS on ovarian reserve and clinical pregnancy outcomes in recent years is inevitable. This study screened people who received repeated IVF/ICSI cycles and performed statistical analysis using a self-control method, aiming to robustly and reliably elucidate whether repeated COS alters ovarian reserve function and clinical pregnancy outcomes. Materials And Methods 1、 Study design and population We assembled people who received one and multiple COS-IVF/ICSI fresh cycles at the First Affiliated Hospital of Zhengzhou University Reproductive Center from January 2015 to March 2021. Ultimately, we administered a retrospective study of medical records of 45,555 cycles from 39,641 patients according to the inclusion and exclusion criteria. This retrospective study was approved by the Ethics Committee of the First Affiliated Hospital of Zhengzhou University (reference number: 2022-KY-0841-002). The tailored inclusion criteria were as follows: fresh cycles of IVF-ET or ICSI-ET; patients with single cycle and multiple cycles; female COS age between 20–39 years; and the time interval between each COS treatment cycle > 2 months. Following were the criteria for exclusion: patients with infertility factors such as PCOS, endometriosis, uterine anomalies (e.g., unicornuate uterus, bicornuate uterus, etc.), and chromosomal abnormalities; FSH > 15 U/L; and antral follicle count (AFC) < 3. The patients were grouped based on the number of repeated cycles in the included population: Group A (No-repeat cycles, single cycle group, n = 34,738); Group B (Repeat cycle 2 group, 4,138 patients, 8,276 cycles); Group C (Repeat cycle 3 group, 593 patients, 1,779 cycles); Group D (Repeat cycle 4 group, 116 patients, 464 cycles); Group E (Repeat cycle 5 group, 38 patients, 190 cycles). The patients in repeated cycle groups (Group B, C, D, and E) were further divided into subgroups based on the number of cycles: Cycle 1 and Cycle 2 for Group B; Cycle 1, Cycle 2 and Cycle 3 for Group C; Cycle 1, Cycle 2, Cycle 3 and Cycle 4 for Group D; Cycle 1, Cycle 2, Cycle 3, Cycle 4 and Cycle 5 for Group E. 2、Outcome measures The primary observables translating ovarian reserve function were antral follicle count (AFC) and anti-Müllerian hormone (AMH), while the secondary observables were basal follicle-stimulating hormone (FSH) and basal luteinizing hormone (LH). We calculated clinical pregnancy rate (CPR), live birth rates (LBR), and early miscarriage rate (EMR) to symbolize clinical pregnancy outcomes. CPR was defined as the number of clinical pregnancies per 100 embryones transferred cycles. The LBR referred to the number of pregnancies that progressed to the delivery of a viable offspring per 100 embryo transplanted cycles. The EMR was calculated as cycles of a pregnancy loss before 28 weeks of gestation and all biochemical pregnancies/total number of clinical pregnancy cycles. 3、ART protocols COS was accomplished with gonadotropin-releasing hormone (GnRH) agonist and antagonist protocols. The COS protocol and Gn initiation dose were determined according to the patient's age, body mass index (BMI), follicle count, and medical history. The Gn dose during ovulation induction was adjusted according to endocrine levels and follicle development. The Center's article described the details of these protocols [ 7 ]. When follicles ≥ 2 reached a diameter of ≥ 18 mm or more than 2/3 of follicles reached a diameter ≥ 16 mm, ovulation was triggered by Aizer (Merck Serono, Italy) or hCG (Lizhu Medicine). Transvaginal ultrasound-guided oocyte retrieval was conducted approximately 37 hours after ovulation. IVF and/or ICSI were performed for fertilization. Depending on the patient's condition and embryo development, one or two D3/D5 embryo(s) were selected for transfer. Luteal support was initiated on the day of oocyte retrieval with daily transvaginal progesterone (Xenotong, Merck Serono, Switzerland) and oral progesterone (Dupbaston, Abbott, Holland). The serum chorionic gonadotropin (β-hCG) levels > 50 IU/mL at 14 or 18 days after the embryo transfer were considered as biochemically pregnant. With the luteal phase support continued and abdominal ultrasound was performed 35 days after the transplant to determine if they were clinically pregnant. Patients with clinical pregnancy were then followed up periodically by telephone to obtain their obstetric results, and this information was recorded in the central archives. 4、Statistical analysis Data were analyzed utilizing SPSS version 25.0 software. Continuous numerical variables were represented by mean ± SD. This study proposed to conduct a self-matching method in the multi-cycle patients. Baseline comparisons of repeated cycles for multi-cycle patients applied paired t-tests or ANOVA with repeated measures design. Wilcoxon signed-rank test was applied for those with uneven variances or non-normal distributions. Categorical variables were represented by frequency and percentage (%), and frequencies were compared with the Chi-square test and Fisher's exact test. Multifactorial logistic regression analysis was exploited to control for potential confounders. Adjusted advantage ratios (aOR) and 95% confidence intervals (CIs) were calculated for the included variables. Line and bar charts were employed to delineate increasing cycles trends in CPR, LBR, and EMR. p < 0.05 was considered a statistically significant difference. Results Comparison of ovarian reserve function Table 1 A Comparison of ovarian reserve function in COS-IVF/ICSI treatment Variable Group A: No-repeat cycles (n = 34,738) Group B: Repeat cycle 2 Group C: Repeat cycle 3 Cycle 1(n = 4,138) Cycle 2(n = 4,138) P value Cycle 1(n = 593) Cycle 2 (n = 593) Cycle 3 (n = 593) P value Age (y) 30.05 ± 4.12 30.77 ± 4.37 31.57 ± 4.27 0.000 31.70 ± 4.21 32.32 ± 4.17* 33.06 ± 4.08*γ 0.000 BMI(Kg/m 2 ) 22.89 ± 3.27 22.82 ± 3.62 23.08 ± 3.15 0.000 22.69 ± 3.08 22.81 ± 3.07* 22.97 ± 3.01*γ 0.000 Basal FSH 6.52 ± 1.86 7.00 ± 2.22 6.99 ± 2.27 0.283 7.32 ± 2.44 7.35 ± 2.53 7.34 ± 2.57 0.715 Basal LH 6.07 ± 12.81 5.42 ± 4.28 5.45 ± 5.81 0.740 5.03 ± 3.14 5.16 ± 5.87 5.16 ± 6.52 0.843 Basal E2 125.69 ± 537.32 93.55 ± 422.03 298.57 ± 914.60 0.000 66.68 ± 206.50 261.39 ± 805.34* 467.17 ± 1127.38*γ 0.000 AMH 4.22 ± 3.42 3.13 ± 2.80 3.12 ± 2.78 0.081 2.28 ± 2.57 2.27 ± 2.58 2.26 ± 2.58 0.438 AFC 15.59 ± 6.41 12.98 ± 6.52 12.90 ± 6.53 0.002 10.93 ± 6.27 10.85 ± 6.22 10.79 ± 6.31 0.083 BMI, Body mass index; FSH, follicle-stimulating hormone; LH, luteinizing Hormone; AMH, Anti-Müllerian hormone; AFC, Antral Follicle Count. * Significantly different from cycle1 in Group C; γ Significantly different from cycle 2 in Group C. Bonferroni correction has adjusted significance values for multiple tests. Table 1 B Comparison of ovarian reserve function in COS-IVF/ICSI treatment Variable Group D: Reapt cycle 4 Group E: Reapt cycle 5 Cycle 1(n = 116) Cycle 2 (n = 116) Cycle 3 (n = 116) Cycle 4 (n = 116) P value Cycle 1(n = 38) Cycle 2(n = 38) Cycle 3(n = 38) Cycle 4(n = 38) Cycle 5(n = 38) P value Age(y) 31.73 ± 4.34 32.25 ± 4.27# 33.05 ± 4.19#c 33.78 ± 4.02#cd 0.000 33.47 ± 3.24 33.84 ± 3.26 34.37 ± 3.19a 34.95 ± 3.10ab 35.53 ± 3.03abfg 0.000 BMI(Kg/m 2 ) 22.47 ± 3.02 22.61 ± 2.99# 22.86 ± 3.00# 22.98 ± 2.95#c 0.000 23.07 ± 2.87 23.17 ± 2.92 23.24 ± 2.89 23.20 ± 2.77 23.34 ± 2.76 0.248 Basal FSH 7.66 ± 2.64 7.63 ± 2.52 7.61 ± 2.58 7.44 ± 2.41 0.714 7.92 ± 2.99 7.96 ± 2.96 8.01 ± 3.10 8.20 ± 3.13 8.20 ± 3.02 0.903 Basal LH 5.74 ± 7.25 5.59 ± 7.40 5.04 ± 7.21 5.32 ± 7.86 0.261 3.94 ± 1.54 3.79 ± 1.56 4.15 ± 2.93 3.78 ± 1.82 3.92 ± 2.35 0.835 Basal E2 78.12 ± 140.05 216.41 ± 625.57 386.28 ± 984.63# 373.13 ± 822.19# 0.000 45.17 ± 33.59 198.13 ± 506.90 148.32 ± 314.80 233.56 ± 479.35 328.59 ± 549.10 a 0.024 AMH 1.35 ± 1.14 1.35 ± 1.13 1.33 ± 1.38 1.36 ± 1.19 0.746 1.33 ± 1.45 1.23 ± 1.42 1.09 ± 1.03 1.12 ± 1.40 1.20 ± 1.40 0.119 AFC 8.64 ± 4.77 8.59 ± 4.81 8.59 ± 4.98 8.66 ± 5.39 0.671 8.92 ± 6.06 8.68 ± 6.15 8.87 ± 6.50 8.87 ± 6.50 8.87 ± 6.50 0.736 BMI, Body mass index; FSH, follicle-stimulating hormone; LH, luteinizing Hormone; AMH, Anti-Müllerian hormone; AFC, Antral Follicle Count. #, Significantly different from Cycle 1 in Group D; c, Significantly different from Cycle 2 in Group D; d, Significantly different from Cycle 3 in Group D. a, Significantly different from Cycle 1 in Group E; b, Significantly different from Cycle 2 in Group E; f, Significantly different from Cycle 3 in Group E; g, Significantly different from Cycle 4 in Group E. Bonferroni correction has adjusted significance values for multiple tests. After filtering through the inclusion and exclusion criteria, we ultimately subsumed 45,555 COS-IVF/ICSI fresh cycles from 39,641 patients, which were segregated into five groups (groups A, B, C, D, and E) based on the number of repeated cycles. We anatomized age, BMI, and indicators levels translating ovarian reserve function, such as AMH, AFC, basal FSH, and basal LH, in each group and performed intra-group self-control comparisons. As depicted in Table 1 (Table 1 A and Table 1 B), there existed a considerable differences ( P < 0.001) pertaining to age or BMI in the repeated cycle groups (Groups B, C, D, and E). Age and BMI in Group C and age in Group D were boosted with an escalating number of cycles ( P 0.05), while Cycle 5 BMI was reported as the highest. Cycles 1, 2, 3, and 4 in Group E exhibited lower age than Cycle 5 ( P 0.05). Among the indicators symbolizing ovarian reserve function, basal FSH, basal LH, AMH, and AFC exhibit no significant distinction ( P > 0.05), but basal E2 was significantly different in Groups B, C, and D ( P < 0.05). Two-by-two comparisons of basal E2 revealed all three cycles in Group C were significantly distinct, with the basal E2 value increasing in a cycle-dependent manner ( P < 0.05). Only Cycle 4 and Cycle 5 were apparently higher than Cycle 1 in Group D ( P < 0.05); Cycle 5 E2 was the highest in Group E ( P < 0.05). Comparison Of Pregnancy Outcomes In Populations With Different Numbers Of Repetitions Table 2 Logistic regression of CPR, LBR and AR with different number of repetitions CPR LBR EMR aOR 95% CI P value aOR 95% CI P value aOR 95% CI P value Group A Reference Reference Reference Group B 0.31 0.28–0.34 0.000 0.28 0.26–0.31 0.000 2.47 2.11–2.88 0.000 Group C 0.17 0.14–0.20 0.000 0.15 0.12–0.19 0.000 3.41 2.37–4.89 0.000 Group D 0.22 0.15–0.33 0.000 0.13 0.08–0.22 0.000 5.13 2.52–10.42 0.000 Group E 0.08 0.03–0.20 0.000 0.02 0.003–0.14 0.000 25.60 2.95-222.45 0.000 Adjusted for age, BMI, basal FSH, basal LH, basal E2, AFC, AMH, number of eggs obtained, treatment protocol, total FSH days, total FSH dosage, endometrial thickness, fertilization method, stage of embryo transferred, and number of embryos transferred. The CPR, LBR, and AR for the population with different numbers of repetitions were calculated to describe their pregnancy outcomes, as shown in Figure 1. As the number of population repetitions increased, CPR (r = - 0.922, P = 0.026) and LBR (r = - 0.920, P = 0.027) showed a downward trend, while EMR followed an upward trend (r = 0.957, P = 0.011). CPR ranged from 69.84% to 11.27%, LBR from 59.21% to 2.82%, and AR from 11.15% to 75.00%. Furthermore, to explore the effects of different repeat cohorts on pregnancy outcomes, we included potential confounding variables such as age, BMI, basal FSH, basal LH, basal E2, AFC, AMH, the number of eggs retrieval, treatment regimen, total FSH days, total FSH dosage, endometrial thickness, fertilization method, stage of embryo transferred, and the number of embryos transferred, and performed logistic regression analysis. The results are visible in Table 2. As compared to Group A, the clinical pregnancy odds of Group B, Group C, Group D and Group E were reduced by 69% (aOR = 0.31; 95% CI, 0.28–0.34; P = 0.000), 83% (aOR = 0.17; 95% CI, 0.14–0.20; P = 0.000), 78% (aOR = 0.22; 95% CI, 0.15–0.33; P = 0.000), and 92% (aOR = 0.08; 95% CI, 0.03–0.20; P = 0.000). Compared to Group A, the other groups experience a decreased amount of viable birth to varying degree ( P = 0.000), whereas, the odds of miscarriage increased in all other groups ( P = 0.000). After excluding the potential confounding factors, we found that the population with more repetitions exhibit poorer pregnancy outcomes. Comparison Of Pregnancy Outcomes Across Cycles In The Same Repeated Cohort In addition, CPR, LBR, and EMR were calculated and plotted as bar graphs for different population cycles with different numbers of repetitions (i.e., Groups B, C, D, and E). As disported in Fig. 2 A, Cycle 1 exhibited significantly higher CPR than Cycle 2 in Group B (19.24% vs 54.88%, P = 0.000); the highest CPR was shown by Cycle 3 (43.44%, P = 0.000) and the lowest was reported for Cycle 2 (12.13%, P = 0.000) in Group C; the difference in CPR between the first three cycles of Group D was not statistically significant, and Cycle 4 reported the highest CPR (52.50%, P = 0.000); there was no difference in CPR in Group E. As displayed in Fig. 2 B, Cycle 1 was significantly higher than Cycle 2 in Group B (5.00% vs. 44.38%, P = 0.000) in LBR; both Group C (35.94%, P = 0.000) and Group D (37.50%, P = 0.000) had the highest LBR in the last cycle; no difference in CPR in Group E. As shown in Fig. 2 C, both Groups B (13.38%, P = 0.000) and C (14.39%, P = 0.000) had the lowest EMR in the last cycle, and there was no statistical difference between cycles in Groups D and E. Table 3 Logistic regression of different cycles for different repetitions of the population on CPR, LBR and EMR CPR LBR EMR aOR 95% CI P value aOR 95% CI P value aOR 95% CI P value Group B Cycle1 Reference Reference Reference Cycle2 8.29 6.80-10.12 0.000 37.68 27.18–52.23 0.000 0.04 0.03–0.06 0.000 Group C Cycle1 Reference Reference Reference Cycle2 0.67 0.33–1.36 0.270 1.00 0.19–5.26 0.990 0.94 0.12–7.71 0.960 Cycle3 6.05 3.28–11.15 0.000 47.59 13.50-167.77 0.000 0.02 0.003-0.10 0.000 Group D Cycle1 Reference Reference Reference Cycle2 2.13 0.31–14.54 0.440 - - 1.000 2.79 0.12–66.77 0.530 Cycle3 4.37 0.74–25.97 0.110 - - 1.000 2.17 0.11–44.38 0.620 Cycle4 20.46 3.05-137.24 0.002 - - 1.000 2.62 0.09–73.12 0.570 Group E Cycle1 Reference Reference Reference Cycle2 0.66 0.03–13.71 0.789 - - - - - - Cycle3 3.02 0.21–44.42 0.418 - - - - - - Cycle4 1.38 0.08–22.88 0.832 - - - - - - Cycle5 8.76 0.47-164.95 0.147 - - - - - - Adjusted for age, BMI, basal FSH, basal LH, basal E2, AFC, AMH, number of eggs obtained, treatment protocol, total FSH days, total FSH dosage, endometrial thickness, fertilization method, stage of embryo transferred, and number of embryos transferred. - No results for too little data. As observed in Table 3 , Cycle 2 (aOR = 8.29; 95% CI, 6.80-10.12; P = 0.000) in Group B, Cycle 3 (aOR = 6.05; 95% CI, 3.28–11.15; P = 0.000) in Group C, and Cycle 4 (aOR = 20.46; 95% CI, 3.05-137.24; P = 0.002) in Group D had the highest CPR within each group; Cycle 2 in Group B (aOR = 37.68; 95% CI, 27.18–52.23; P = 0.000 and aOR = 0.04; 95% CI, 0.03–0.06; P = 0.000) and Cycle 3 in Group C (aOR = 47.59; 95% CI, 13.50- 167.77; P = 0.000, aOR = 0.02; 95% CI, 0.003-0.10; P = 0.000) had the highest LBR and lowest EMR within each group, the remaining groups did not reached the level of statistical significance. The present study revealed that a raise in cycle number significantly increases CPR in the cohort of ≤ 4 repeated cycles, improved LBR, and reduced EMR in cohorts with ≤ 3 repeated cycles, which could be derived from the above study results. Hence, the patients are not advised for another attempt when do not have a successful pregnancy after 4 attempts based on cost and pregnancy outcome considerations, depicted in Fig. 3 . Discussion The present study is based on a broad population of patients undergoing COS and IVF/ICSI with fresh embryo transfer and validated with a reliable and rigorous analysis revealing that repeated COS-IVF/ICSI does not impact ovarian reserve function; however, it influences the clinical pregnancy outcome. We ascertained that the population with a higher number of repetitions ended up with the worse clinical pregnancy outcome. Intriguingly, there exhibited opposite results in the population with the same number of repetition that multiple COS-IVF/ICSI enhanced CPR in Groups B, C, and D and ameliorated LBR and EMR in Groups B and C. However, the modifications in CPR, LBR, and EMR did not reach the statistical significance up to 5 repetitions, implying that COS-IVF/ICSI in the cohort of repeated cycles ≤ 4 times in infertile patients is favorable for pregnancy outcomes. The present study is noteworthy in that, to the best of our knowledge, it is the most extensive study to date examining the effects of repeated COS on ovarian reserve and clinical pregnancy outcomes in fresh cycles. Ovarian reserve, which symbolizes the number of oocytes retained in the ovary, is more influenced by factors such as genetics, age, and environment [ 8 ]. Hence a population with a repertoire of multiple COS was chosen for self-control comparison to amplify the reliability of the study findings. The current study guidelines tailored AMH and AFC as the most representative predictors of ovarian function, the simplest, the most sensitive, and superior to day-3 FSH [ 8 , 9 ]. Other indicators can be used as auxiliary judgments. The AMH, AFC, basal FSH, and basal LH levels were not significantly different among cycles in Groups B, C, D, and E, whereas only basal E2 levels aggrandized with the increase in cycle number. The present data suggested basal E2 levels as the only suitable auxiliary indicator for precisely interpreting normal basal FSH values and hampered its use as an ovarian reserve function indicator [ 9 ]. Therefore, findings revealed that repeated COS does not affect ovarian reserve function. A systematic review by Luk et al [ 1 ] concluded that repeated COS does not negatively impact the ovarian reserve function within ≤ 3 cycles. Xu et al [ 10 ] picked basal FSH, LH, E2 levels, and AFC to assess ovarian reserve function and demonstrated that the impact of COS on ovarian reserve function was not significant up to 4 cycles, but they did not compare different groups for the difference in AMH levels between cycles. This study further indicates that 5 treatment cycles still do not affect ovarian reserve function. In contrast, the puncture during the retrieval of oocytes damages the capillaries and follicles of the ovary [ 1 ]. A previous study has observed that high concentrations of anti-ovarian antibodies in infertile patients undergoing multiple IVF caused by repeated punctures were correlated with a decrease in eggs after stimulation [ 11 ]. Whether COS after 5 repeats negatively correlates with ovarian reserve function is, therefore, necessary to be investigated. The present study revealed that the clinical pregnancy outcomes measured by the CPR, LBR, and EMR deteriorated considerably as repeated populations increased. The findings of the regression analysis revealed that decreasing age (aOR = 0.96; 95% CI, 0.95–0.97; P = 0.000) and increasing AFC (aOR = 1.02; 95% CI, 1.01–1.03; P = 0.000) significantly influenced clinical pregnancies, which implied increasing age and declining ovarian reserve function are potential reasons for performing COS-IVF/ICSI repeat. Poor clinical pregnancy outcomes associated with older age and more repeat cohorts are apprehensible, yet the number of repeats still significantly affects clinical pregnancy outcomes after controlling potential confounders such as age, BMI, and AFC. Furthermore, the CPR in the cohort ≤ 4-cycle and the LBR in the ≤ 3-cycle cohorts were found significantly higher after multiple COS-IVF/ICSI by self-control analysis in the same repeat count population. The findings revealed that repeat COS in ≤ 4 cycles positively affects clinical pregnancy outcomes while the CPR at Cycle 5 is insignificant to the clinical pregnancy outcomes. Homburg et al. [ 12 ] reported a considerable decrease in CPR after three cycles, but this study did not perform a further regression analysis to obtain more reliable results. Likewise, another study strengthened that repeated COS did not negatively affect CPR and LBR in patients experiencing three cycles and less until after > 3 cycles [ 1 ]. A multicenter study by Meldrum et al. [ 13 ] illustrated a significant reduction in CPR for > 4 cycles and LBR for ≥ 4 cycles. It is reassuring that the present study came up with the similar results. Additionally, there was a significant enhancement in oocyte number, fertilization outcome, and embryo quality upon increasing the number of cycles beyond 3 COS repeats in egg donors [ 14 ]. Similarly, another study reported a substantial increase in fertilization and CPR in patients with repeated COS cycles compared to unrepeated cycles saving did not further differentiate repeated cycles by number [ 6 ]. Nevertheless, the CPR was stable in patients with 4 to 8 cycles under 42 years of age, hence defining the appropriate age and cycles for patients after analyzing pregnancy outcomes from 4 (169 women) to 8 (27 women) cycles of treatment [ 15 ]. The cumulative effect of three complete IVF/ICSI cycles (hereafter referred to as multiple cycles) is considered by NICE to increase the chance of successful pregnancy to 45–53% in infertile patients under 40 years of age, which is the most cost-effective and clinically efficient option [ 16 ]. Thereby, the organization proffers that IVF/ICSI treatment should be planned on a multi-cycle basis. The present study stated that the CPR of three and four consecutive complete cycles reached 43.44% and 52.50%, respectively. A cross-sectional survey conducted by Harrison et al. [ 17 ] in 2021 on willingness to plan for multiple cycles contended that most patients preferred three completed cycles of IVF/ICSI (referred to as multiple cycles) treatment, unlike the current cycle-by-cycle treatment plan. In addition, emotional and physical stress are the main factors attributable to many infertility patients who discontinue treatment rather than financial costs [ 18 ]. Therefore, the patients undergoing treatment or experiencing treatment failure needed expert counseling and encouragement to enlighten the spark of hope among them. If the ART treatment process is defined as a multi-cycle process, pre-planning the multi-cycle treatment is necessary to make fully aware of the patient with associative risk of implantation and pregnancy failure and discuss the treatment strategy to follow after treatment failure with patients in advance in order to achieve patients' parenting goals sooner and better [ 17 , 19 ]. More research is needed in the future to evaluate the feasibility and acceptability of this treatment planning approach. This study exhibited that a raise in cycle number significantly increases CPR in the cohort of ≤ 4 repeated cycles, improves LBR, and reduces EMR in cohorts with ≤ 3 repeated cycles. The validity of advising patients to actively try 4 attempts in this study can be derived from the above study results, which enlighten hope and encouragement in infertile patients. Consequently, the patients are not advised for another attempt; however, adoption may be considered a feasible option if infertile patients do not have a successful pregnancy after 4 attempts based on cost and pregnancy outcome considerations. Nevertheless, the possibility of achieving clinical pregnancy with normal birth after 4 cycles is not denied. The small number of patients undergoing COS > 5 times in the clinic makes statistical analysis difficult, whereas a distinctive study can be designed to analyze them in an animal model. Antonouli et al. [ 20 ] reported that the oviducts of mice receiving 4 and 8 gonadotropin stimulation did not perceive significant morphological changes but underwent significant ultrastructural alterations, including a dramatic decrease in ciliated cells and massive mitochondrial degeneration compared to controls (who did not receive stimulation). These alterations were more pronounced at 8 than 4 times, which may negatively affect the fertilization process and embryo transport to the uterus. The research team working on this topic previously demonstrated that repeated (6 and 8 times) gonadotropin stimulation leads to overexpression or overactivation of intracellular localization/content of proteins controlling cell cycle progression in the oviduct and ovary of mice, causes damage to the oocyte spindle, which reduces reproductive performance in mice [ 21 ]. Nevertheless has no significant effect on mice that suffer 4 times stimulation [ 22 ]. Likewise, the first stimulation cycle resulted in a 3-fold increase in oocytes, yet the number of oocytes decreased as the number of stimulations increased. The frequency of mitochondria in mouse oocytes with uneven distribution increased significantly, increasing spindle breakage and intracellular oxidative stress and decreasing expression of octamer-binding transcription factor 4 (Oct4) after four cycles [ 23 ]. Nie et al [ 24 ] created a mouse model of premature ovarian failure (POF) by more than 10 successive COS. They detected that successive COS induced ovarian oxidative stress, apoptosis, and ovarian damage through various mechanisms, including p16 and SIRT1/FOXO1 signaling pathways, reduced ovarian function and oocyte quality. However, it is manifested that repeated ovarian stimulation (10 times) significantly declined the number of primary follicles compared to single ovarian stimulation. In contrast, it did not affect autophagy, proliferation, apoptosis, and aging of the ovary [ 25 ]. These mice trials reported the detrimental effects of recurrent ovarian stimulation on the integrity of the fallopian tubes, ovaries, and oocytes and the potential to increase the risk of gynecological malignancies. Clinical studies have also revealed that COS-induced physiologically high levels of E2 may increase the risk of cancer in estrogen-sensitive tissues such as ovarian, uterine, and breast tissues [ 26 – 28 ]. Yet, the issue remains controversial, with some researchers’ findings denying an increased risk of cancer in the COS group, possibly due to inconsistent drug exposure times and short follow-up periods [ 29 , 30 ]. In addition, it has been demonstrated that repeated COS increases the venture of osteoporosis and cardiovascular disease by accelerating ovarian aging [ 31 ]. Although the mouse model is the most commonly used model for clinical studies, the present mouse experimental evaluations yielded many exciting results. What cannot be ignored is the variability between humans and mice, and the primate model is perhaps more accurate. Dong et al [ 32 ] revealed that although no significant abnormalities in follicle activation and growth and no serious damage to ovarian structure and function in repeatedly receiving COH in rhesus monkeys after 5 years. Nevertheless, granulosa cells of Mitochondria were impaired, in which StAR and P450arom protein expression was downregulated, inhibiting cell proliferation and differentiation and possibly negatively impacting ovarian function. The team also explored the effects on uterine and mammary tissues after 5 years in rhesus monkeys experiencing four COS. It proved that uterine cells displayed a low proliferative state and mammary epithelial cells depicted low proliferation and high apoptosis, and no cancer risk was observed in both [ 33 ]. However, the small sample size limited both studies and their conclusions (experimental group n = 3). Larger sample sizes and longer-term studies would provide a more comprehensive picture of the question under investigation. The potential adverse effects of repeated COS on ovarian function were detected in both the mouse model and the rhesus monkey model above, yet did not produce serious damage to their phenotypes, which abnegate the adverse effects of repeated COS on ovarian reserve function in clinical case-control studies. Nevertheless, the possibility of significant functional changes in these organs after a longer period of potential damage cannot be guaranteed. The strength of this study is the utility of self-control comparisons since it diminishes the influence of numerous uncontrollable factors such as genetics and environment, making the results and conclusions more reliable. Second, the study used univariate comparisons and multifactorial logistic regression analyses to compensate for potential confounding factors' effects on clinical pregnancy outcomes. Third, strict exclusion criteria were implemented to preclude patients with PCOS, endometriosis, and genetic factors for infertility and patients with ovarian hyporesponsiveness with FSH > 15 U/L and AFC < 3. Fourth, the study explored the effect of repeat COS on clinical pregnancy outcomes, an aspect less frequently investigated in articles, and scant information are available in publications. Moreover, to our knowledge, this is the largest sample size, and the subgroups are more detailed, making the findings more convincing. A drawback of the present analysis is that it is an observational study with unavoidable inherent flaws and is unable to collect and control for all possible confounding factors. Still, the study used a reliable study design. The self-control comparison itself has reduced the uncontrollability of retrospective studies. Additionally, the data from this study only allowed grouping to the 5-repeat cycle population, and exploration was not extended to the most frequent populations. However, the effect of the number of repeats on clinical pregnancy outcomes has reached an inflection point, where CPR no longer increases significantly after 4 times. Conclusion In conclusion, the study confirms that ovarian reserve function did not change significantly after repeated COS (≤ 5 times). Further studies to determine whether ovarian function alters with more repetitions are necessary. There is a significant effect of the number of repeated COS on pregnancy outcome, with a strong enhancement in overall CPR and LBR and a significant decrease in overall EMR with an increasing number of repetitions in different populations. In contrast, rise in number of COS increases the CPR in the cohort of ≤ 4 repetitions population, improves LBR, and reduces EMR in the ≤ 3 repetitions population within the same population. It is concluded that the patients are counseled to undergo COS ≤ 4 times, whereas, not recommended to undertake the COS 5 times or more. Abbreviations ART: Assisted reproductive technology; IVF: In-vitro fertilization; ICSI: Intracytoplasmic sperm injection; COS: Controlled ovarian stimulation; IVF-ET: In-vitro fertilization-embryo transfer; AFC: Antral follicle count; AMH: Anti-Müllerian hormone; FSH: Follicle-stimulating hormone; LH: Luteinizing hormone; CPR: Clinical pregnancy rates; LBR: Live birth rates; EMR: Early miscarriage rate; aOR: Adjusted odds ratio; BMI: Body mass index; CI: Confidential interval Declarations Ethics approval and consent to participate This retrospective study was approved by the Ethics Committee of the First Affiliated Hospital of Zhengzhou University (reference number: 2022-KY-0841-002). Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This work was supported by the Chinese Natural Science Funds Youth Funds (81701505). Authors' contributions LQ developed the original concept of this study. LQ, SMW and YCS participated in the study design. SMW, YPL, XLC and NNW participated in data collection, SMW conducted data analysis and interpretation and the writing of the original version of the manuscript. All authors participated in the manuscript revision. All authors have contributed to critical discussion and reviewed the final version. Acknowledgements The authors would like to thank to the Chinese Natural Science Funds Youth Funds for providing financial support. References Luk J, Arici A. Does the ovarian reserve decrease from repeated ovulation stimulations? Curr Opin Obstet Gynecol. 2010;22(3):177–82. Farhi J, Homburg R, Ferber A, Orvieto R, Ben Rafael Z. Non-response to ovarian stimulation in normogonadotrophic, normogonadal women: a clinical sign of impending onset of ovarian failure pre-empting the rise in basal follicle stimulating hormone levels. Hum Reprod. 1997;12(2):241–3. Van der Auwera I, D'Hooghe T. Superovulation of female mice delays embryonic and fetal development. Hum Reprod. 2001;16(6):1237–43. Van Blerkom J, Davis P. Differential effects of repeated ovarian stimulation on cytoplasmic and spindle organization in metaphase II mouse oocytes matured in vivo and in vitro. Hum Reprod. 2001;16(4):757–64. Martin-Johnston MK, Uhler ML, Grotjan HE, Lifchez AS, Nani JM, Beltsos AN. Lower chance of pregnancy with repeated cycles with in vitro fertilization. J Reprod Med. 2009;54(2):67–72. Ni H, He S, Li H, Chen D, Hua R, Chen S, Quan S. [Ovarian response and pregnancy outcome in hyper-responders during repeated in vitro fertilization and embryo transfer]. Nan Fang Yi Ke Da Xue Xue Bao. 2015;35(6):912–5. Hu L, Bu Z, Guo Y, Su Y, Zhai J, Sun Y. Comparison of different ovarian hyperstimulation protocols efficacy in poor ovarian responders according to the Bologna criteria. Int J Clin Exp Med. 2014;7(4):1128–34. Tal R, Seifer DB. Ovarian reserve testing: a user's guide. Am J Obstet Gynecol. 2017;217(2):129–40. Medicine PC, o t. A S f R, Electronic address aao P C o t A S f, M. R. Testing and interpreting measures of ovarian reserve: a committee opinion. Fertil Steril. 2020;114(6):1151–7. Xu J, Shi J, Wang C. Impact of repeated controlled ovarian stimulation on ovarian reserve and response. J Reprod Med. 2020;29(2):176–81. Gobert B, Barbarino-Monnier P, Guillet-May F, Béné MC, Faure GC. Anti-ovary antibodies after attempts at human in vitro fertilization induced by follicular puncture rather than hormonal stimulation. J Reprod Fertil. 1992;96(1):213–8. Homburg R, Meltcer S, Rabinson J, Scharf S, Anteby EY, Orvieto R. Is there a limit for the number of in vitro fertilization cycles for an individual patient? Fertil Steril. 2009;91(4 Suppl):1329–31. Meldrum DR, Silverberg KM, Bustillo M, Stokes L. Success rate with repeated cycles of in vitro fertilization-embryo transfer. Fertil Steril. 1998;69(6):1005–9. Paul LT, Atilan O, Tulay P. The effect of repeated controlled ovarian stimulation cycles on the gamete and embryo development. Zygote. 2019;27(5):347–9. Yovel I, Geva E, Lessing JB, Yaron Y, Botchan A, Amit A. Analysis of the fourth to eighth in-vitro fertilization treatments after three previously failed attempts. Hum Reprod. 1994;9(4):738–41. Nice: National Institute for Health and Care Excellence: Guidelines, Fertility problems: assessment and treatment, London: National Institute for Health and Care Excellence (NICE) Copyright © NICE 2020., 2013. Harrison C, Gameiro S, Boivin J. Patient willingness, preferences and decision-making about planning for three complete cycles of IVF/ICSI treatment. Hum Reprod. 2021;36(5):1339–52. Hammarberg K, Astbury J, Baker H. Women's experience of IVF: a follow-up study. Hum Reprod. 2001;16(2):374–83. Gameiro S. It is beneficial to support young, good prognosis patients, who strongly desire a biological child, through multiple cycles of treatment. Fertil Steril. 2021;116(1):67–8. Antonouli S, Palmerini MG, Bianchi S, Rossi G, Cecconi S, Belli M, Bernardi S, Khalili MA, Familiari G, Nottola SA, et al. Repeated hyperstimulation affects the ultrastructure of mouse fallopian tube epithelium. J Reprod Dev. 2020;66(4):387–97. Di Nisio V, Rossi G, Palmerini MG, Macchiarelli G, Tiboni GM, Cecconi S. Increased rounds of gonadotropin stimulation have side effects on mouse fallopian tubes and oocytes. Reproduction. 2018;155(3):245–50. Di Luigi G, Rossi G, Castellucci A, Leocata P, Carta G, Canipari R, Nottola SA, Cecconi S. Repeated ovarian stimulation does not affect the expression level of proteins involved in cell cycle control in mouse ovaries and fallopian tubes. J Assist Reprod Genet. 2014;31(6):717–24. Kalthur G, Salian SR, Nair R, Mathew J, Adiga SK, Kalthur SG, Zeegers D, Hande MP. Distribution pattern of cytoplasmic organelles, spindle integrity, oxidative stress, octamer-binding transcription factor 4 (Oct4) expression and developmental potential of oocytes following multiple superovulation. Reprod Fertil Dev. 2016;28(12):2027–38. Nie X, Dai Y, Zheng Y, Bao D, Chen Q, Yin Y, Fu H, Hou D. Establishment of a Mouse Model of Premature Ovarian Failure Using Consecutive Superovulation. Cell Physiol Biochem. 2018;51(5):2341–58. Whang J, Ahn C, Kim S, Seok E, Yang Y, Han G, Jo H, Yang H. Effects of Repeated Ovarian Stimulation on Ovarian Function and Aging in Mice. Dev Reprod. 2021;25(4):213–23. Rizzuto I, Behrens RF, Smith LA. Risk of ovarian cancer in women treated with ovarian stimulating drugs for infertility. Cochrane Database Syst Rev. 2019;6(6):Cd008215. van Leeuwen FE, Klip H, Mooij TM, van de Swaluw AM, Lambalk CB, Kortman M, Laven JS, Jansen CA, Helmerhorst FM, Cohlen BJ, et al. Risk of borderline and invasive ovarian tumours after ovarian stimulation for in vitro fertilization in a large Dutch cohort. Hum Reprod. 2011;26(12):3456–65. Sanner K, Conner P, Bergfeldt K, Dickman P, Sundfeldt K, Bergh T, Hagenfeldt K, Janson PO, Nilsson S, Persson I. Ovarian epithelial neoplasia after hormonal infertility treatment: long-term follow-up of a historical cohort in Sweden. Fertil Steril. 2009;91(4):1152–8. Beebeejaun Y, Athithan A, Copeland TP, Kamath MS, Sarris I, Sunkara SK. Risk of breast cancer in women treated with ovarian stimulation drugs for infertility: a systematic review and meta-analysis. Fertil Steril. 2021;116(1):198–207. Silva Idos S, Wark PA, McCormack VA, Mayer D, Overton C, Little V, Nieto J, Hardiman P, Davies M. MacLean A B. Ovulation-stimulation drugs and cancer risks: a long-term follow-up of a British cohort. Br J Cancer. 2009;100(11):1824–31. Zhang J, Lai Z, Shi L, Tian Y, Luo A, Xu Z, Ma X, Wang S. Repeated superovulation increases the risk of osteoporosis and cardiovascular diseases by accelerating ovarian aging in mice. Aging. 2018;10(5):1089–102. Dong G, Guo Y, Cao H, Zhou T, Zhou Z, Sha J, Guo X, Zhu H. Long-term effects of repeated superovulation on ovarian structure and function in rhesus monkeys. Fertil Steril. 2014;102(5):1452-7.e1. Yan P, Xu J, Zeng Y, Dong G, Cao H, Zheng M, Zhu H. Long-term effects of repeated superovulation on the uterus and mammary gland in rhesus monkeys. J Assist Reprod Genet. 2017;34(4):535–45. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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 In Review Editorial Policies 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-2189441","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":146818310,"identity":"941785d0-47da-4390-a362-109605f7b414","order_by":0,"name":"Lin Qi","email":"","orcid":"","institution":"The First Affiliated Hospital of Zhengzhou University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lin","middleName":"","lastName":"Qi","suffix":""},{"id":146818311,"identity":"e1328d29-6cee-4a31-847e-0829f36b37a3","order_by":1,"name":"Shiming Wang","email":"","orcid":"","institution":"The First Affiliated Hospital of Zhengzhou University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shiming","middleName":"","lastName":"Wang","suffix":""},{"id":146818312,"identity":"296e0fe7-4083-4ef2-9b4f-b970a00417b9","order_by":2,"name":"Yaping Liu","email":"","orcid":"","institution":"The First Affiliated Hospital of Zhengzhou University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yaping","middleName":"","lastName":"Liu","suffix":""},{"id":146818313,"identity":"2ab76b8f-59d6-4d2e-b8de-e181a99e18c9","order_by":3,"name":"Xiaoli Chen","email":"","orcid":"","institution":"The First Affiliated Hospital of Zhengzhou University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xiaoli","middleName":"","lastName":"Chen","suffix":""},{"id":146818314,"identity":"970adc58-bff4-423e-bf56-37830ad7ae3f","order_by":4,"name":"Ningning Wang","email":"","orcid":"","institution":"The First Affiliated Hospital of Zhengzhou University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ningning","middleName":"","lastName":"Wang","suffix":""},{"id":146818315,"identity":"c1804ad5-4035-44aa-aa04-32febf14cc3f","order_by":5,"name":"Yingchun Su","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYJCCA0CcwMDA2PggocKGJC3MzQYPzqQRbxNQC3ub5MO2Q4SVys/IMTxc8Msuz+B2Y1tFAtsBBv727gS8Wgxu5BgcntmXXGxw52DbjQSeOwwSZ85uwK9FAqiFt+dA4oYbiUAtEs+AIrn4tQAdhtBSkGBwmLAWBpDDeH5AtDAkJBChxeDMs4LDvA3JiTNvJDZLJBxI4yHoF/n25M2fef7YJfbdSH/48ec/Gzn+9l4CDmPgMGBgbENweQgoBwH2BwwMf4hQNwpGwSgYBSMXAACyyVVW31lXVgAAAABJRU5ErkJggg==","orcid":"","institution":"The First Affiliated Hospital of Zhengzhou University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Yingchun","middleName":"","lastName":"Su","suffix":""}],"badges":[],"createdAt":"2022-10-21 07:44:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2189441/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2189441/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":28349030,"identity":"a43712eb-6628-4ddd-a341-620e338e4bec","added_by":"auto","created_at":"2022-10-27 20:03:48","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":157022,"visible":true,"origin":"","legend":"\u003cp\u003eLine chart of total CPR, LBR and EMR in the population with different numbers of repetitions. CPR, clinical pregnancy rate; LBR, live birth rates; EMR, early miscarriage rate.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-2189441/v1/3dd9e61917532d8d294057a4.png"},{"id":28349032,"identity":"e8d1dc4c-e619-4a0a-8659-197f6b0b2d54","added_by":"auto","created_at":"2022-10-27 20:03:48","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":305957,"visible":true,"origin":"","legend":"\u003cp\u003eA Histogram of CPR for different cycles in repeated cohorts. CPR, clinical pregnancy rate.\u003c/p\u003e\n\u003cp\u003eB Histogram of LBR for different cycles in repeated cohorts. LBR, live birth rates.\u003c/p\u003e\n\u003cp\u003eC Histogram of EMR for different cycles in repeated cohorts. EMR, early miscarriage rate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ea significantly different from Cycle1 in Group B.\u003c/p\u003e\n\u003cp\u003eb significantly different from Cycle1 in Group C; β significantly different from Cycle2 in Group C.\u003c/p\u003e\n\u003cp\u003ec significantly different from Cycle1 in Group D; α significantly different from Cycle2 in Group D; e significantly different from Cycle3 in Group D.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-2189441/v1/b3d7375b1ffb40d4c0e7eb45.png"},{"id":28349031,"identity":"e6854132-e984-4612-881e-bb95cba8b102","added_by":"auto","created_at":"2022-10-27 20:03:48","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":418637,"visible":true,"origin":"","legend":"\u003cp\u003eRecommendations for infertile couples with multiple COS-IVF/ICSI.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-2189441/v1/bb97cd6e2a936ec1e63f72c7.png"},{"id":28555124,"identity":"51583dd4-9b39-4af1-8d58-279a00ae70e7","added_by":"auto","created_at":"2022-11-02 10:59:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1105875,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2189441/v1/478ce5c9-84d5-4a5b-8128-52ea75f4e44d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Continue or quit? -- Recommendations for repeated controlled ovarian stimulation therapy","fulltext":[{"header":"Background","content":"\u003cp\u003eAssisted reproductive technology (ART), especially in-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI), has been fleetly evolved to aid infertile couples in achieving a pregnancy. The artificial induction of superovulation by gonadotropin injection, known as controlled ovarian stimulation (COS), is a necessary step in in-vitro fertilization-embryo transfer (IVF-ET). However, it is ambiguous whether the ovarian stimulation with supraphysiologic hormonal doses impacts ovarian functions or pregnancy outcomes. Moreover, most infertile women require multiple COS to increase the chances of clinical pregnancy [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Information on the health effects of multiple COS in infertile women is scarce and needs a comprehensive debate over the existing gaps. Therefore, further thought and extensive research are required to analyze the effect of repeated COS on the health of infertile women.\u003c/p\u003e \u003cp\u003eThe Ovarian reserve function symbolizes a woman's fertility potential. Some studies have sought to clarify that high doses of exogenous gonadotropins may have depleted follicular reserve at an accelerated rate [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It has been reported that repeated COS does not affect ovarian reserve function and clinical pregnancy rates (CPR) in the first three cycles [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, repetitive ovarian stimulation resulted in ovarian oxidative stress damage, mitochondrial DNA mutations, the heightened proportion of oocyte spindle defects, and reduced oocyte quality in mice [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Martin-Johnston et al. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] have demonstrated that CPR tends to decline with increasing cycle number, especially after the third cycle. Conversely, Prior publication has queried a conflicting result that repeated COS significantly increases the CPR [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Thus, studies exploring the impact of repeat COS on ovarian reserve function and pregnancy outcome have yielded conflicting or inconclusive results.\u003c/p\u003e \u003cp\u003eFurthermore, relevant retrospective studies are relatively scarce, chiefly in the last century, and ART techniques have seen innovation and improvement in the previous 20 years. Consequently, a large-scale updated article investigating the effects of repeated COS on ovarian reserve and clinical pregnancy outcomes in recent years is inevitable. This study screened people who received repeated IVF/ICSI cycles and performed statistical analysis using a self-control method, aiming to robustly and reliably elucidate whether repeated COS alters ovarian reserve function and clinical pregnancy outcomes.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e1、 Study design and population\u003c/h2\u003e \u003cp\u003eWe assembled people who received one and multiple COS-IVF/ICSI fresh cycles at the First Affiliated Hospital of Zhengzhou University Reproductive Center from January 2015 to March 2021. Ultimately, we administered a retrospective study of medical records of 45,555 cycles from 39,641 patients according to the inclusion and exclusion criteria. This retrospective study was approved by the Ethics Committee of the First Affiliated Hospital of Zhengzhou University (reference number: 2022-KY-0841-002).\u003c/p\u003e \u003cp\u003eThe tailored inclusion criteria were as follows: fresh cycles of IVF-ET or ICSI-ET; patients with single cycle and multiple cycles; female COS age between 20\u0026ndash;39 years; and the time interval between each COS treatment cycle\u0026thinsp;\u0026gt;\u0026thinsp;2 months. Following were the criteria for exclusion: patients with infertility factors such as PCOS, endometriosis, uterine anomalies (e.g., unicornuate uterus, bicornuate uterus, etc.), and chromosomal abnormalities; FSH\u0026thinsp;\u0026gt;\u0026thinsp;15 U/L; and antral follicle count (AFC)\u0026thinsp;\u0026lt;\u0026thinsp;3.\u003c/p\u003e \u003cp\u003eThe patients were grouped based on the number of repeated cycles in the included population: Group A (No-repeat cycles, single cycle group, n\u0026thinsp;=\u0026thinsp;34,738); Group B (Repeat cycle 2 group, 4,138 patients, 8,276 cycles); Group C (Repeat cycle 3 group, 593 patients, 1,779 cycles); Group D (Repeat cycle 4 group, 116 patients, 464 cycles); Group E (Repeat cycle 5 group, 38 patients, 190 cycles). The patients in repeated cycle groups (Group B, C, D, and E) were further divided into subgroups based on the number of cycles: Cycle 1 and Cycle 2 for Group B; Cycle 1, Cycle 2 and Cycle 3 for Group C; Cycle 1, Cycle 2, Cycle 3 and Cycle 4 for Group D; Cycle 1, Cycle 2, Cycle 3, Cycle 4 and Cycle 5 for Group E.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2、Outcome measures\u003c/h2\u003e \u003cp\u003eThe primary observables translating ovarian reserve function were antral follicle count (AFC) and anti-M\u0026uuml;llerian hormone (AMH), while the secondary observables were basal follicle-stimulating hormone (FSH) and basal luteinizing hormone (LH). We calculated clinical pregnancy rate (CPR), live birth rates (LBR), and early miscarriage rate (EMR) to symbolize clinical pregnancy outcomes. CPR was defined as the number of clinical pregnancies per 100 embryones transferred cycles. The LBR referred to the number of pregnancies that progressed to the delivery of a viable offspring per 100 embryo transplanted cycles. The EMR was calculated as cycles of a pregnancy loss before 28 weeks of gestation and all biochemical pregnancies/total number of clinical pregnancy cycles.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e3、ART protocols\u003c/h2\u003e \u003cp\u003eCOS was accomplished with gonadotropin-releasing hormone (GnRH) agonist and antagonist protocols. The COS protocol and Gn initiation dose were determined according to the patient's age, body mass index (BMI), follicle count, and medical history. The Gn dose during ovulation induction was adjusted according to endocrine levels and follicle development. The Center's article described the details of these protocols [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. When follicles\u0026thinsp;\u0026ge;\u0026thinsp;2 reached a diameter of \u0026ge;\u0026thinsp;18 mm or more than 2/3 of follicles reached a diameter\u0026thinsp;\u0026ge;\u0026thinsp;16 mm, ovulation was triggered by Aizer (Merck Serono, Italy) or hCG (Lizhu Medicine). Transvaginal ultrasound-guided oocyte retrieval was conducted approximately 37 hours after ovulation. IVF and/or ICSI were performed for fertilization. Depending on the patient's condition and embryo development, one or two D3/D5 embryo(s) were selected for transfer. Luteal support was initiated on the day of oocyte retrieval with daily transvaginal progesterone (Xenotong, Merck Serono, Switzerland) and oral progesterone (Dupbaston, Abbott, Holland). The serum chorionic gonadotropin (β-hCG) levels\u0026thinsp;\u0026gt;\u0026thinsp;50 IU/mL at 14 or 18 days after the embryo transfer were considered as biochemically pregnant. With the luteal phase support continued and abdominal ultrasound was performed 35 days after the transplant to determine if they were clinically pregnant. Patients with clinical pregnancy were then followed up periodically by telephone to obtain their obstetric results, and this information was recorded in the central archives.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e4、Statistical analysis\u003c/h2\u003e \u003cp\u003eData were analyzed utilizing SPSS version 25.0 software. Continuous numerical variables were represented by mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD. This study proposed to conduct a self-matching method in the multi-cycle patients. Baseline comparisons of repeated cycles for multi-cycle patients applied paired t-tests or ANOVA with repeated measures design. Wilcoxon signed-rank test was applied for those with uneven variances or non-normal distributions. Categorical variables were represented by frequency and percentage (%), and frequencies were compared with the Chi-square test and Fisher's exact test. Multifactorial logistic regression analysis was exploited to control for potential confounders. Adjusted advantage ratios (aOR) and 95% confidence intervals (CIs) were calculated for the included variables. Line and bar charts were employed to delineate increasing cycles trends in CPR, LBR, and EMR. \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered a statistically significant difference.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv class=\"Section2\" id=\"Sec8\"\u003e\n \u003ch2\u003eComparison of ovarian reserve function\u003c/h2\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eA Comparison of ovarian reserve function in COS-IVF/ICSI treatment\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"10\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eGroup A: No-repeat cycles (n\u0026thinsp;=\u0026thinsp;34,738)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eGroup B: Repeat cycle 2\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eGroup C: Repeat cycle 3\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCycle 1(n\u0026thinsp;=\u0026thinsp;4,138)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCycle 2(n\u0026thinsp;=\u0026thinsp;4,138)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCycle 1(n\u0026thinsp;=\u0026thinsp;593)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCycle 2\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;593)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCycle 3\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;593)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (y)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30.05\u0026thinsp;\u0026plusmn;\u0026thinsp;4.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30.77\u0026thinsp;\u0026plusmn;\u0026thinsp;4.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e31.57\u0026thinsp;\u0026plusmn;\u0026thinsp;4.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e31.70\u0026thinsp;\u0026plusmn;\u0026thinsp;4.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32.32\u0026thinsp;\u0026plusmn;\u0026thinsp;4.17*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33.06\u0026thinsp;\u0026plusmn;\u0026thinsp;4.08*\u0026gamma;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBMI(Kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22.89\u0026thinsp;\u0026plusmn;\u0026thinsp;3.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22.82\u0026thinsp;\u0026plusmn;\u0026thinsp;3.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23.08\u0026thinsp;\u0026plusmn;\u0026thinsp;3.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22.69\u0026thinsp;\u0026plusmn;\u0026thinsp;3.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22.81\u0026thinsp;\u0026plusmn;\u0026thinsp;3.07*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22.97\u0026thinsp;\u0026plusmn;\u0026thinsp;3.01*\u0026gamma;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBasal FSH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.52\u0026thinsp;\u0026plusmn;\u0026thinsp;1.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.00\u0026thinsp;\u0026plusmn;\u0026thinsp;2.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.99\u0026thinsp;\u0026plusmn;\u0026thinsp;2.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.283\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.32\u0026thinsp;\u0026plusmn;\u0026thinsp;2.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.35\u0026thinsp;\u0026plusmn;\u0026thinsp;2.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.34\u0026thinsp;\u0026plusmn;\u0026thinsp;2.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.715\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBasal LH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.07\u0026thinsp;\u0026plusmn;\u0026thinsp;12.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.42\u0026thinsp;\u0026plusmn;\u0026thinsp;4.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.45\u0026thinsp;\u0026plusmn;\u0026thinsp;5.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.740\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.03\u0026thinsp;\u0026plusmn;\u0026thinsp;3.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.16\u0026thinsp;\u0026plusmn;\u0026thinsp;5.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.16\u0026thinsp;\u0026plusmn;\u0026thinsp;6.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.843\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBasal E2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e125.69\u0026thinsp;\u0026plusmn;\u0026thinsp;537.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e93.55\u0026thinsp;\u0026plusmn;\u0026thinsp;422.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e298.57\u0026thinsp;\u0026plusmn;\u0026thinsp;914.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e66.68\u0026thinsp;\u0026plusmn;\u0026thinsp;206.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e261.39\u0026thinsp;\u0026plusmn;\u0026thinsp;805.34*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e467.17\u0026thinsp;\u0026plusmn;\u0026thinsp;1127.38*\u0026gamma;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAMH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.22\u0026thinsp;\u0026plusmn;\u0026thinsp;3.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.13\u0026thinsp;\u0026plusmn;\u0026thinsp;2.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.12\u0026thinsp;\u0026plusmn;\u0026thinsp;2.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.081\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.28\u0026thinsp;\u0026plusmn;\u0026thinsp;2.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.27\u0026thinsp;\u0026plusmn;\u0026thinsp;2.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.26\u0026thinsp;\u0026plusmn;\u0026thinsp;2.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.438\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAFC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15.59\u0026thinsp;\u0026plusmn;\u0026thinsp;6.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12.98\u0026thinsp;\u0026plusmn;\u0026thinsp;6.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12.90\u0026thinsp;\u0026plusmn;\u0026thinsp;6.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10.93\u0026thinsp;\u0026plusmn;\u0026thinsp;6.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10.85\u0026thinsp;\u0026plusmn;\u0026thinsp;6.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10.79\u0026thinsp;\u0026plusmn;\u0026thinsp;6.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.083\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\"\u003eBMI, Body mass index; FSH, follicle-stimulating hormone; LH, luteinizing Hormone; AMH, Anti-M\u0026uuml;llerian hormone; AFC, Antral Follicle Count.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\"\u003e* Significantly different from cycle1 in Group C; \u0026gamma; Significantly different from cycle 2 in Group C.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eBonferroni correction has adjusted significance values for multiple tests.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab2\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eB Comparison of ovarian reserve function in COS-IVF/ICSI treatment\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"17\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003eGroup D: Reapt cycle 4\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"6\"\u003e\n \u003cp\u003eGroup E: Reapt cycle 5\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCycle 1(n\u0026thinsp;=\u0026thinsp;116)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCycle 2 (n\u0026thinsp;=\u0026thinsp;116)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCycle 3 (n\u0026thinsp;=\u0026thinsp;116)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCycle 4 (n\u0026thinsp;=\u0026thinsp;116)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eCycle 1(n\u0026thinsp;=\u0026thinsp;38)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCycle 2(n\u0026thinsp;=\u0026thinsp;38)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCycle 3(n\u0026thinsp;=\u0026thinsp;38)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCycle 4(n\u0026thinsp;=\u0026thinsp;38)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCycle 5(n\u0026thinsp;=\u0026thinsp;38)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge(y)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31.73\u0026thinsp;\u0026plusmn;\u0026thinsp;4.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.25\u0026thinsp;\u0026plusmn;\u0026thinsp;4.27#\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.05\u0026thinsp;\u0026plusmn;\u0026thinsp;4.19#c\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.78\u0026thinsp;\u0026plusmn;\u0026thinsp;4.02#cd\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e33.47\u0026thinsp;\u0026plusmn;\u0026thinsp;3.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.84\u0026thinsp;\u0026plusmn;\u0026thinsp;3.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34.37\u0026thinsp;\u0026plusmn;\u0026thinsp;3.19a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34.95\u0026thinsp;\u0026plusmn;\u0026thinsp;3.10ab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.53\u0026thinsp;\u0026plusmn;\u0026thinsp;3.03abfg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBMI(Kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.47\u0026thinsp;\u0026plusmn;\u0026thinsp;3.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.61\u0026thinsp;\u0026plusmn;\u0026thinsp;2.99#\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.86\u0026thinsp;\u0026plusmn;\u0026thinsp;3.00#\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.98\u0026thinsp;\u0026plusmn;\u0026thinsp;2.95#c\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e23.07\u0026thinsp;\u0026plusmn;\u0026thinsp;2.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.17\u0026thinsp;\u0026plusmn;\u0026thinsp;2.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.24\u0026thinsp;\u0026plusmn;\u0026thinsp;2.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.20\u0026thinsp;\u0026plusmn;\u0026thinsp;2.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.34\u0026thinsp;\u0026plusmn;\u0026thinsp;2.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0.248\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBasal FSH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.66\u0026thinsp;\u0026plusmn;\u0026thinsp;2.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.63\u0026thinsp;\u0026plusmn;\u0026thinsp;2.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.61\u0026thinsp;\u0026plusmn;\u0026thinsp;2.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.44\u0026thinsp;\u0026plusmn;\u0026thinsp;2.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0.714\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e7.92\u0026thinsp;\u0026plusmn;\u0026thinsp;2.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.96\u0026thinsp;\u0026plusmn;\u0026thinsp;2.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.01\u0026thinsp;\u0026plusmn;\u0026thinsp;3.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.20\u0026thinsp;\u0026plusmn;\u0026thinsp;3.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.20\u0026thinsp;\u0026plusmn;\u0026thinsp;3.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0.903\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBasal LH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.74\u0026thinsp;\u0026plusmn;\u0026thinsp;7.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.59\u0026thinsp;\u0026plusmn;\u0026thinsp;7.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.04\u0026thinsp;\u0026plusmn;\u0026thinsp;7.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.32\u0026thinsp;\u0026plusmn;\u0026thinsp;7.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0.261\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e3.94\u0026thinsp;\u0026plusmn;\u0026thinsp;1.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.79\u0026thinsp;\u0026plusmn;\u0026thinsp;1.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.15\u0026thinsp;\u0026plusmn;\u0026thinsp;2.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.78\u0026thinsp;\u0026plusmn;\u0026thinsp;1.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.92\u0026thinsp;\u0026plusmn;\u0026thinsp;2.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0.835\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBasal E2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e78.12\u0026thinsp;\u0026plusmn;\u0026thinsp;140.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e216.41\u0026thinsp;\u0026plusmn;\u0026thinsp;625.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e386.28\u0026thinsp;\u0026plusmn;\u0026thinsp;984.63#\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e373.13\u0026thinsp;\u0026plusmn;\u0026thinsp;822.19#\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e45.17\u0026thinsp;\u0026plusmn;\u0026thinsp;33.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e198.13\u0026thinsp;\u0026plusmn;\u0026thinsp;506.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e148.32\u0026thinsp;\u0026plusmn;\u0026thinsp;314.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e233.56\u0026thinsp;\u0026plusmn;\u0026thinsp;479.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e328.59\u0026thinsp;\u0026plusmn;\u0026thinsp;549.10 a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.024\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAMH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.35\u0026thinsp;\u0026plusmn;\u0026thinsp;1.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.35\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.36\u0026thinsp;\u0026plusmn;\u0026thinsp;1.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0.746\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e1.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.23\u0026thinsp;\u0026plusmn;\u0026thinsp;1.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.09\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.12\u0026thinsp;\u0026plusmn;\u0026thinsp;1.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.20\u0026thinsp;\u0026plusmn;\u0026thinsp;1.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0.119\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAFC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.64\u0026thinsp;\u0026plusmn;\u0026thinsp;4.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.59\u0026thinsp;\u0026plusmn;\u0026thinsp;4.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.59\u0026thinsp;\u0026plusmn;\u0026thinsp;4.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.66\u0026thinsp;\u0026plusmn;\u0026thinsp;5.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0.671\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e8.92\u0026thinsp;\u0026plusmn;\u0026thinsp;6.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.68\u0026thinsp;\u0026plusmn;\u0026thinsp;6.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.87\u0026thinsp;\u0026plusmn;\u0026thinsp;6.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.87\u0026thinsp;\u0026plusmn;\u0026thinsp;6.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.87\u0026thinsp;\u0026plusmn;\u0026thinsp;6.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0.736\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"17\"\u003eBMI, Body mass index; FSH, follicle-stimulating hormone; LH, luteinizing Hormone; AMH, Anti-M\u0026uuml;llerian hormone; AFC, Antral Follicle Count.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"17\"\u003e#, Significantly different from Cycle 1 in Group D; c, Significantly different from Cycle 2 in Group D; d, Significantly different from Cycle 3 in Group D.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003ea, Significantly different from Cycle 1 in Group E; b, Significantly different from Cycle 2 in Group E; f, Significantly different from Cycle 3 in Group E; g, Significantly different from Cycle 4 in Group E.\u003c/p\u003e\n \u003cp\u003eBonferroni correction has adjusted significance values for multiple tests.\u003c/p\u003e\n \u003cp\u003eAfter filtering through the inclusion and exclusion criteria, we ultimately subsumed 45,555 COS-IVF/ICSI fresh cycles from 39,641 patients, which were segregated into five groups (groups A, B, C, D, and E) based on the number of repeated cycles. We anatomized age, BMI, and indicators levels translating ovarian reserve function, such as AMH, AFC, basal FSH, and basal LH, in each group and performed intra-group self-control comparisons.\u003c/p\u003e\n \u003cp\u003eAs depicted in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eA and Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eB), there existed a considerable differences (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) pertaining to age or BMI in the repeated cycle groups (Groups B, C, D, and E). Age and BMI in Group C and age in Group D were boosted with an escalating number of cycles (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). BMI in Group D was significantly distinguishable except for Cycle 2 vs. Cycle 3 and Cycle 3 vs. Cycle 4 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), while Cycle 5 BMI was reported as the highest. Cycles 1, 2, 3, and 4 in Group E exhibited lower age than Cycle 5 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Whereas the differences in BMI among the five cycles in Group E did not reach statistical significance (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\n \u003cp\u003eAmong the indicators symbolizing ovarian reserve function, basal FSH, basal LH, AMH, and AFC exhibit no significant distinction (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), but basal E2 was significantly different in Groups B, C, and D (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Two-by-two comparisons of basal E2 revealed all three cycles in Group C were significantly distinct, with the basal E2 value increasing in a cycle-dependent manner (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Only Cycle 4 and Cycle 5 were apparently higher than Cycle 1 in Group D (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05); Cycle 5 E2 was the highest in Group E (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eComparison Of Pregnancy Outcomes In Populations With Different Numbers Of Repetitions\u003c/h3\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab3\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eLogistic regression of CPR, LBR and AR with different number of repetitions\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"12\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eCPR\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eLBR\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eEMR\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eaOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"BoldItalic\" name=\"Emphasis\" type=\"BoldItalic\"\u003eP\u003c/span\u003e \u003cstrong\u003evalue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eaOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"BoldItalic\" name=\"Emphasis\" type=\"BoldItalic\"\u003eP\u003c/span\u003e \u003cstrong\u003evalue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eaOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"BoldItalic\" name=\"Emphasis\" type=\"BoldItalic\"\u003eP\u003c/span\u003e \u003cstrong\u003evalue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup A\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup B\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.28\u0026ndash;0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.26\u0026ndash;0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.11\u0026ndash;2.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup C\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.14\u0026ndash;0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.12\u0026ndash;0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.37\u0026ndash;4.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup D\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.15\u0026ndash;0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.08\u0026ndash;0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.52\u0026ndash;10.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup E\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.03\u0026ndash;0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.003\u0026ndash;0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.95-222.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"12\"\u003eAdjusted for age, BMI, basal FSH, basal LH, basal E2, AFC, AMH, number of eggs obtained, treatment protocol, total FSH days, total FSH dosage, endometrial thickness, fertilization method, stage of embryo transferred, and number of embryos transferred.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe CPR, LBR, and AR for the population with different numbers of repetitions were calculated to describe their pregnancy outcomes, as shown in Figure 1. As the number of population repetitions increased, CPR (r = - 0.922, \u003cem\u003eP\u003c/em\u003e = 0.026) and LBR (r = - 0.920, \u003cem\u003eP\u003c/em\u003e = 0.027) showed a downward trend, while EMR followed an upward trend (r = 0.957, \u003cem\u003eP\u003c/em\u003e = 0.011). CPR ranged from 69.84% to 11.27%, LBR from 59.21% to 2.82%, and AR from 11.15% to 75.00%.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurthermore, to explore the effects of different repeat cohorts on pregnancy outcomes, we included potential confounding variables such as age, BMI, basal FSH, basal LH, basal E2, AFC, AMH, the number of eggs retrieval, treatment regimen, total FSH days, total FSH dosage, endometrial thickness, fertilization method, stage of embryo transferred, and the number of embryos transferred, and performed logistic regression analysis. The results are visible in Table 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs compared to Group A, the clinical pregnancy odds of Group B, Group C, Group D and Group E were reduced by 69% (aOR\u0026thinsp;=\u0026thinsp;0.31; 95% CI, 0.28\u0026ndash;0.34; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000), 83% (aOR\u0026thinsp;=\u0026thinsp;0.17; 95% CI, 0.14\u0026ndash;0.20; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000), 78% (aOR\u0026thinsp;=\u0026thinsp;0.22; 95% CI, 0.15\u0026ndash;0.33; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000), and 92% (aOR\u0026thinsp;=\u0026thinsp;0.08; 95% CI, 0.03\u0026ndash;0.20; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000). Compared to Group A, the other groups experience a decreased amount of viable birth to varying degree (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000), whereas, the odds of miscarriage increased in all other groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000). After excluding the potential confounding factors, we found that the population with more repetitions exhibit poorer pregnancy outcomes.\u003c/p\u003e\n\u003ch3\u003eComparison Of Pregnancy Outcomes Across Cycles In The Same Repeated Cohort\u003c/h3\u003e\n\u003cp\u003eIn addition, CPR, LBR, and EMR were calculated and plotted as bar graphs for different population cycles with different numbers of repetitions (i.e., Groups B, C, D, and E). As disported in Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eA, Cycle 1 exhibited significantly higher CPR than Cycle 2 in Group B (19.24% vs 54.88%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000); the highest CPR was shown by Cycle 3 (43.44%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000) and the lowest was reported for Cycle 2 (12.13%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000) in Group C; the difference in CPR between the first three cycles of Group D was not statistically significant, and Cycle 4 reported the highest CPR (52.50%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000); there was no difference in CPR in Group E. As displayed in Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eB, Cycle 1 was significantly higher than Cycle 2 in Group B (5.00% vs. 44.38%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000) in LBR; both Group C (35.94%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000) and Group D (37.50%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000) had the highest LBR in the last cycle; no difference in CPR in Group E. As shown in Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eC, both Groups B (13.38%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000) and C (14.39%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000) had the lowest EMR in the last cycle, and there was no statistical difference between cycles in Groups D and E.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab4\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eLogistic regression of different cycles for different repetitions of the population on CPR, LBR and EMR\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"13\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eCPR\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eLBR\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eEMR\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eaOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eaOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eaOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup B\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.80-10.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.18\u0026ndash;52.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.03\u0026ndash;0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup C\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.33\u0026ndash;1.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.270\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.19\u0026ndash;5.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.990\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.12\u0026ndash;7.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.960\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.28\u0026ndash;11.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.50-167.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.003-0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup D\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.31\u0026ndash;14.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.440\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.12\u0026ndash;66.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.530\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.74\u0026ndash;25.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.110\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.11\u0026ndash;44.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.620\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.05-137.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.09\u0026ndash;73.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.570\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup E\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.03\u0026ndash;13.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.789\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.21\u0026ndash;44.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.418\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.08\u0026ndash;22.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.832\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.47-164.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.147\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"13\"\u003eAdjusted for age, BMI, basal FSH, basal LH, basal E2, AFC, AMH, number of eggs obtained, treatment protocol, total FSH days, total FSH dosage, endometrial thickness, fertilization method, stage of embryo transferred, and number of embryos transferred.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e- No results for too little data.\u003c/p\u003e\n\u003cp\u003eAs observed in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e, Cycle 2 (aOR\u0026thinsp;=\u0026thinsp;8.29; 95% CI, 6.80-10.12; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000) in Group B, Cycle 3 (aOR\u0026thinsp;=\u0026thinsp;6.05; 95% CI, 3.28\u0026ndash;11.15; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000) in Group C, and Cycle 4 (aOR\u0026thinsp;=\u0026thinsp;20.46; 95% CI, 3.05-137.24; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002) in Group D had the highest CPR within each group; Cycle 2 in Group B (aOR\u0026thinsp;=\u0026thinsp;37.68; 95% CI, 27.18\u0026ndash;52.23; P\u0026thinsp;=\u0026thinsp;0.000 and aOR\u0026thinsp;=\u0026thinsp;0.04; 95% CI, 0.03\u0026ndash;0.06; P\u0026thinsp;=\u0026thinsp;0.000) and Cycle 3 in Group C (aOR\u0026thinsp;=\u0026thinsp;47.59; 95% CI, 13.50- 167.77; P\u0026thinsp;=\u0026thinsp;0.000, aOR\u0026thinsp;=\u0026thinsp;0.02; 95% CI, 0.003-0.10; P\u0026thinsp;=\u0026thinsp;0.000) had the highest LBR and lowest EMR within each group, the remaining groups did not reached the level of statistical significance.\u003c/p\u003e\n\u003cp\u003eThe present study revealed that a raise in cycle number significantly increases CPR in the cohort of \u0026le;\u0026thinsp;4 repeated cycles, improved LBR, and reduced EMR in cohorts with \u0026le;\u0026thinsp;3 repeated cycles, which could be derived from the above study results. Hence, the patients are not advised for another attempt when do not have a successful pregnancy after 4 attempts based on cost and pregnancy outcome considerations, depicted in Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study is based on a broad population of patients undergoing COS and IVF/ICSI with fresh embryo transfer and validated with a reliable and rigorous analysis revealing that repeated COS-IVF/ICSI does not impact ovarian reserve function; however, it influences the clinical pregnancy outcome. We ascertained that the population with a higher number of repetitions ended up with the worse clinical pregnancy outcome. Intriguingly, there exhibited opposite results in the population with the same number of repetition that multiple COS-IVF/ICSI enhanced CPR in Groups B, C, and D and ameliorated LBR and EMR in Groups B and C. However, the modifications in CPR, LBR, and EMR did not reach the statistical significance up to 5 repetitions, implying that COS-IVF/ICSI in the cohort of repeated cycles\u0026thinsp;\u0026le;\u0026thinsp;4 times in infertile patients is favorable for pregnancy outcomes. The present study is noteworthy in that, to the best of our knowledge, it is the most extensive study to date examining the effects of repeated COS on ovarian reserve and clinical pregnancy outcomes in fresh cycles.\u003c/p\u003e \u003cp\u003eOvarian reserve, which symbolizes the number of oocytes retained in the ovary, is more influenced by factors such as genetics, age, and environment [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Hence a population with a repertoire of multiple COS was chosen for self-control comparison to amplify the reliability of the study findings. The current study guidelines tailored AMH and AFC as the most representative predictors of ovarian function, the simplest, the most sensitive, and superior to day-3 FSH [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Other indicators can be used as auxiliary judgments. The AMH, AFC, basal FSH, and basal LH levels were not significantly different among cycles in Groups B, C, D, and E, whereas only basal E2 levels aggrandized with the increase in cycle number. The present data suggested basal E2 levels as the only suitable auxiliary indicator for precisely interpreting normal basal FSH values and hampered its use as an ovarian reserve function indicator [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Therefore, findings revealed that repeated COS does not affect ovarian reserve function.\u003c/p\u003e \u003cp\u003eA systematic review by Luk et al [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] concluded that repeated COS does not negatively impact the ovarian reserve function within \u0026le;\u0026thinsp;3 cycles. Xu et al [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] picked basal FSH, LH, E2 levels, and AFC to assess ovarian reserve function and demonstrated that the impact of COS on ovarian reserve function was not significant up to 4 cycles, but they did not compare different groups for the difference in AMH levels between cycles. This study further indicates that 5 treatment cycles still do not affect ovarian reserve function. In contrast, the puncture during the retrieval of oocytes damages the capillaries and follicles of the ovary [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. A previous study has observed that high concentrations of anti-ovarian antibodies in infertile patients undergoing multiple IVF caused by repeated punctures were correlated with a decrease in eggs after stimulation [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Whether COS after 5 repeats negatively correlates with ovarian reserve function is, therefore, necessary to be investigated.\u003c/p\u003e \u003cp\u003eThe present study revealed that the clinical pregnancy outcomes measured by the CPR, LBR, and EMR deteriorated considerably as repeated populations increased. The findings of the regression analysis revealed that decreasing age (aOR\u0026thinsp;=\u0026thinsp;0.96; 95% CI, 0.95\u0026ndash;0.97; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000) and increasing AFC (aOR\u0026thinsp;=\u0026thinsp;1.02; 95% CI, 1.01\u0026ndash;1.03; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000) significantly influenced clinical pregnancies, which implied increasing age and declining ovarian reserve function are potential reasons for performing COS-IVF/ICSI repeat. Poor clinical pregnancy outcomes associated with older age and more repeat cohorts are apprehensible, yet the number of repeats still significantly affects clinical pregnancy outcomes after controlling potential confounders such as age, BMI, and AFC. Furthermore, the CPR in the cohort\u0026thinsp;\u0026le;\u0026thinsp;4-cycle and the LBR in the \u0026le;\u0026thinsp;3-cycle cohorts were found significantly higher after multiple COS-IVF/ICSI by self-control analysis in the same repeat count population. The findings revealed that repeat COS in \u0026le;\u0026thinsp;4 cycles positively affects clinical pregnancy outcomes while the CPR at Cycle 5 is insignificant to the clinical pregnancy outcomes.\u003c/p\u003e \u003cp\u003eHomburg et al. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] reported a considerable decrease in CPR after three cycles, but this study did not perform a further regression analysis to obtain more reliable results. Likewise, another study strengthened that repeated COS did not negatively affect CPR and LBR in patients experiencing three cycles and less until after \u0026gt;\u0026thinsp;3 cycles [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. A multicenter study by Meldrum et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] illustrated a significant reduction in CPR for \u0026gt;\u0026thinsp;4 cycles and LBR for \u0026ge;\u0026thinsp;4 cycles. It is reassuring that the present study came up with the similar results. Additionally, there was a significant enhancement in oocyte number, fertilization outcome, and embryo quality upon increasing the number of cycles beyond 3 COS repeats in egg donors [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Similarly, another study reported a substantial increase in fertilization and CPR in patients with repeated COS cycles compared to unrepeated cycles saving did not further differentiate repeated cycles by number [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Nevertheless, the CPR was stable in patients with 4 to 8 cycles under 42 years of age, hence defining the appropriate age and cycles for patients after analyzing pregnancy outcomes from 4 (169 women) to 8 (27 women) cycles of treatment [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe cumulative effect of three complete IVF/ICSI cycles (hereafter referred to as multiple cycles) is considered by NICE to increase the chance of successful pregnancy to 45\u0026ndash;53% in infertile patients under 40 years of age, which is the most cost-effective and clinically efficient option [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Thereby, the organization proffers that IVF/ICSI treatment should be planned on a multi-cycle basis. The present study stated that the CPR of three and four consecutive complete cycles reached 43.44% and 52.50%, respectively. A cross-sectional survey conducted by Harrison et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] in 2021 on willingness to plan for multiple cycles contended that most patients preferred three completed cycles of IVF/ICSI (referred to as multiple cycles) treatment, unlike the current cycle-by-cycle treatment plan. In addition, emotional and physical stress are the main factors attributable to many infertility patients who discontinue treatment rather than financial costs [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Therefore, the patients undergoing treatment or experiencing treatment failure needed expert counseling and encouragement to enlighten the spark of hope among them. If the ART treatment process is defined as a multi-cycle process, pre-planning the multi-cycle treatment is necessary to make fully aware of the patient with associative risk of implantation and pregnancy failure and discuss the treatment strategy to follow after treatment failure with patients in advance in order to achieve patients' parenting goals sooner and better [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. More research is needed in the future to evaluate the feasibility and acceptability of this treatment planning approach.\u003c/p\u003e \u003cp\u003eThis study exhibited that a raise in cycle number significantly increases CPR in the cohort of \u0026le;\u0026thinsp;4 repeated cycles, improves LBR, and reduces EMR in cohorts with \u0026le;\u0026thinsp;3 repeated cycles. The validity of advising patients to actively try 4 attempts in this study can be derived from the above study results, which enlighten hope and encouragement in infertile patients. Consequently, the patients are not advised for another attempt; however, adoption may be considered a feasible option if infertile patients do not have a successful pregnancy after 4 attempts based on cost and pregnancy outcome considerations. Nevertheless, the possibility of achieving clinical pregnancy with normal birth after 4 cycles is not denied.\u003c/p\u003e \u003cp\u003eThe small number of patients undergoing COS\u0026thinsp;\u0026gt;\u0026thinsp;5 times in the clinic makes statistical analysis difficult, whereas a distinctive study can be designed to analyze them in an animal model. Antonouli et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] reported that the oviducts of mice receiving 4 and 8 gonadotropin stimulation did not perceive significant morphological changes but underwent significant ultrastructural alterations, including a dramatic decrease in ciliated cells and massive mitochondrial degeneration compared to controls (who did not receive stimulation). These alterations were more pronounced at 8 than 4 times, which may negatively affect the fertilization process and embryo transport to the uterus. The research team working on this topic previously demonstrated that repeated (6 and 8 times) gonadotropin stimulation leads to overexpression or overactivation of intracellular localization/content of proteins controlling cell cycle progression in the oviduct and ovary of mice, causes damage to the oocyte spindle, which reduces reproductive performance in mice [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Nevertheless has no significant effect on mice that suffer 4 times stimulation [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLikewise, the first stimulation cycle resulted in a 3-fold increase in oocytes, yet the number of oocytes decreased as the number of stimulations increased. The frequency of mitochondria in mouse oocytes with uneven distribution increased significantly, increasing spindle breakage and intracellular oxidative stress and decreasing expression of octamer-binding transcription factor 4 (Oct4) after four cycles [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Nie et al [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] created a mouse model of premature ovarian failure (POF) by more than 10 successive COS. They detected that successive COS induced ovarian oxidative stress, apoptosis, and ovarian damage through various mechanisms, including p16 and SIRT1/FOXO1 signaling pathways, reduced ovarian function and oocyte quality. However, it is manifested that repeated ovarian stimulation (10 times) significantly declined the number of primary follicles compared to single ovarian stimulation. In contrast, it did not affect autophagy, proliferation, apoptosis, and aging of the ovary [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese mice trials reported the detrimental effects of recurrent ovarian stimulation on the integrity of the fallopian tubes, ovaries, and oocytes and the potential to increase the risk of gynecological malignancies. Clinical studies have also revealed that COS-induced physiologically high levels of E2 may increase the risk of cancer in estrogen-sensitive tissues such as ovarian, uterine, and breast tissues [\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Yet, the issue remains controversial, with some researchers\u0026rsquo; findings denying an increased risk of cancer in the COS group, possibly due to inconsistent drug exposure times and short follow-up periods [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In addition, it has been demonstrated that repeated COS increases the venture of osteoporosis and cardiovascular disease by accelerating ovarian aging [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough the mouse model is the most commonly used model for clinical studies, the present mouse experimental evaluations yielded many exciting results. What cannot be ignored is the variability between humans and mice, and the primate model is perhaps more accurate. Dong et al [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] revealed that although no significant abnormalities in follicle activation and growth and no serious damage to ovarian structure and function in repeatedly receiving COH in rhesus monkeys after 5 years. Nevertheless, granulosa cells of Mitochondria were impaired, in which StAR and P450arom protein expression was downregulated, inhibiting cell proliferation and differentiation and possibly negatively impacting ovarian function. The team also explored the effects on uterine and mammary tissues after 5 years in rhesus monkeys experiencing four COS. It proved that uterine cells displayed a low proliferative state and mammary epithelial cells depicted low proliferation and high apoptosis, and no cancer risk was observed in both [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. However, the small sample size limited both studies and their conclusions (experimental group n\u0026thinsp;=\u0026thinsp;3). Larger sample sizes and longer-term studies would provide a more comprehensive picture of the question under investigation.\u003c/p\u003e \u003cp\u003eThe potential adverse effects of repeated COS on ovarian function were detected in both the mouse model and the rhesus monkey model above, yet did not produce serious damage to their phenotypes, which abnegate the adverse effects of repeated COS on ovarian reserve function in clinical case-control studies. Nevertheless, the possibility of significant functional changes in these organs after a longer period of potential damage cannot be guaranteed.\u003c/p\u003e \u003cp\u003eThe strength of this study is the utility of self-control comparisons since it diminishes the influence of numerous uncontrollable factors such as genetics and environment, making the results and conclusions more reliable. Second, the study used univariate comparisons and multifactorial logistic regression analyses to compensate for potential confounding factors' effects on clinical pregnancy outcomes. Third, strict exclusion criteria were implemented to preclude patients with PCOS, endometriosis, and genetic factors for infertility and patients with ovarian hyporesponsiveness with FSH\u0026thinsp;\u0026gt;\u0026thinsp;15 U/L and AFC\u0026thinsp;\u0026lt;\u0026thinsp;3. Fourth, the study explored the effect of repeat COS on clinical pregnancy outcomes, an aspect less frequently investigated in articles, and scant information are available in publications. Moreover, to our knowledge, this is the largest sample size, and the subgroups are more detailed, making the findings more convincing.\u003c/p\u003e \u003cp\u003eA drawback of the present analysis is that it is an observational study with unavoidable inherent flaws and is unable to collect and control for all possible confounding factors. Still, the study used a reliable study design. The self-control comparison itself has reduced the uncontrollability of retrospective studies. Additionally, the data from this study only allowed grouping to the 5-repeat cycle population, and exploration was not extended to the most frequent populations. However, the effect of the number of repeats on clinical pregnancy outcomes has reached an inflection point, where CPR no longer increases significantly after 4 times.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, the study confirms that ovarian reserve function did not change significantly after repeated COS (\u0026le;\u0026thinsp;5 times). Further studies to determine whether ovarian function alters with more repetitions are necessary. There is a significant effect of the number of repeated COS on pregnancy outcome, with a strong enhancement in overall CPR and LBR and a significant decrease in overall EMR with an increasing number of repetitions in different populations. In contrast, rise in number of COS increases the CPR in the cohort of \u0026le;\u0026thinsp;4 repetitions population, improves LBR, and reduces EMR in the \u0026le;\u0026thinsp;3 repetitions population within the same population. It is concluded that the patients are counseled to undergo COS\u0026thinsp;\u0026le;\u0026thinsp;4 times, whereas, not recommended to undertake the COS 5 times or more.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eART: Assisted reproductive technology; IVF: In-vitro fertilization; ICSI: Intracytoplasmic sperm injection; COS: Controlled ovarian stimulation; IVF-ET: In-vitro fertilization-embryo transfer; AFC: Antral follicle count; AMH: Anti-M\u0026uuml;llerian hormone; FSH: Follicle-stimulating hormone; LH: Luteinizing hormone; CPR: Clinical pregnancy rates; LBR: Live birth rates; EMR: Early miscarriage rate; aOR: Adjusted odds ratio; BMI: Body mass index; CI: Confidential interval \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective study was approved by the Ethics Committee of the First Affiliated Hospital of Zhengzhou University (reference number: 2022-KY-0841-002).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Chinese Natural Science Funds Youth Funds (81701505).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLQ developed the original concept of this study. LQ, SMW and YCS participated in the study design. SMW, YPL, XLC and NNW participated in data collection, SMW conducted data analysis and interpretation and the writing of the original version of the manuscript. All authors participated in the manuscript revision. All authors have contributed to critical discussion and reviewed the final version.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank to the Chinese Natural Science Funds Youth Funds for providing financial support.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eLuk J, Arici A. Does the ovarian reserve decrease from repeated ovulation stimulations? Curr Opin Obstet Gynecol. 2010;22(3):177\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eFarhi J, Homburg R, Ferber A, Orvieto R, Ben Rafael Z. Non-response to ovarian stimulation in normogonadotrophic, normogonadal women: a clinical sign of impending onset of ovarian failure pre-empting the rise in basal follicle stimulating hormone levels. Hum Reprod. 1997;12(2):241\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eVan der Auwera I, D\u0026apos;Hooghe T. Superovulation of female mice delays embryonic and fetal development. Hum Reprod. 2001;16(6):1237\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eVan Blerkom J, Davis P. Differential effects of repeated ovarian stimulation on cytoplasmic and spindle organization in metaphase II mouse oocytes matured in vivo and in vitro. Hum Reprod. 2001;16(4):757\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMartin-Johnston MK, Uhler ML, Grotjan HE, Lifchez AS, Nani JM, Beltsos AN. Lower chance of pregnancy with repeated cycles with in vitro fertilization. J Reprod Med. 2009;54(2):67\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eNi H, He S, Li H, Chen D, Hua R, Chen S, Quan S. [Ovarian response and pregnancy outcome in hyper-responders during repeated in vitro fertilization and embryo transfer]. Nan Fang Yi Ke Da Xue Xue Bao. 2015;35(6):912\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHu L, Bu Z, Guo Y, Su Y, Zhai J, Sun Y. Comparison of different ovarian hyperstimulation protocols efficacy in poor ovarian responders according to the Bologna criteria. Int J Clin Exp Med. 2014;7(4):1128\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eTal R, Seifer DB. Ovarian reserve testing: a user\u0026apos;s guide. Am J Obstet Gynecol. 2017;217(2):129\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMedicine PC, o t. A S f R, Electronic address aao P C o t A S f, M. R. Testing and interpreting measures of ovarian reserve: a committee opinion. Fertil Steril. 2020;114(6):1151\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eXu J, Shi J, Wang C. Impact of repeated controlled ovarian stimulation on ovarian reserve and response. J Reprod Med. 2020;29(2):176\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGobert B, Barbarino-Monnier P, Guillet-May F, B\u0026eacute;n\u0026eacute; MC, Faure GC. Anti-ovary antibodies after attempts at human in vitro fertilization induced by follicular puncture rather than hormonal stimulation. J Reprod Fertil. 1992;96(1):213\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHomburg R, Meltcer S, Rabinson J, Scharf S, Anteby EY, Orvieto R. Is there a limit for the number of in vitro fertilization cycles for an individual patient? Fertil Steril. 2009;91(4 Suppl):1329\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMeldrum DR, Silverberg KM, Bustillo M, Stokes L. Success rate with repeated cycles of in vitro fertilization-embryo transfer. Fertil Steril. 1998;69(6):1005\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ePaul LT, Atilan O, Tulay P. The effect of repeated controlled ovarian stimulation cycles on the gamete and embryo development. Zygote. 2019;27(5):347\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eYovel I, Geva E, Lessing JB, Yaron Y, Botchan A, Amit A. Analysis of the fourth to eighth in-vitro fertilization treatments after three previously failed attempts. Hum Reprod. 1994;9(4):738\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eNice: National Institute for Health and Care Excellence: Guidelines, Fertility problems: assessment and treatment, London: National Institute for Health and Care Excellence (NICE) Copyright \u0026copy; NICE 2020., 2013.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHarrison C, Gameiro S, Boivin J. Patient willingness, preferences and decision-making about planning for three complete cycles of IVF/ICSI treatment. Hum Reprod. 2021;36(5):1339\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHammarberg K, Astbury J, Baker H. Women\u0026apos;s experience of IVF: a follow-up study. Hum Reprod. 2001;16(2):374\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGameiro S. It is beneficial to support young, good prognosis patients, who strongly desire a biological child, through multiple cycles of treatment. Fertil Steril. 2021;116(1):67\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAntonouli S, Palmerini MG, Bianchi S, Rossi G, Cecconi S, Belli M, Bernardi S, Khalili MA, Familiari G, Nottola SA, et al. Repeated hyperstimulation affects the ultrastructure of mouse fallopian tube epithelium. J Reprod Dev. 2020;66(4):387\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDi Nisio V, Rossi G, Palmerini MG, Macchiarelli G, Tiboni GM, Cecconi S. Increased rounds of gonadotropin stimulation have side effects on mouse fallopian tubes and oocytes. Reproduction. 2018;155(3):245\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDi Luigi G, Rossi G, Castellucci A, Leocata P, Carta G, Canipari R, Nottola SA, Cecconi S. Repeated ovarian stimulation does not affect the expression level of proteins involved in cell cycle control in mouse ovaries and fallopian tubes. J Assist Reprod Genet. 2014;31(6):717\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKalthur G, Salian SR, Nair R, Mathew J, Adiga SK, Kalthur SG, Zeegers D, Hande MP. Distribution pattern of cytoplasmic organelles, spindle integrity, oxidative stress, octamer-binding transcription factor 4 (Oct4) expression and developmental potential of oocytes following multiple superovulation. Reprod Fertil Dev. 2016;28(12):2027\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eNie X, Dai Y, Zheng Y, Bao D, Chen Q, Yin Y, Fu H, Hou D. Establishment of a Mouse Model of Premature Ovarian Failure Using Consecutive Superovulation. Cell Physiol Biochem. 2018;51(5):2341\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eWhang J, Ahn C, Kim S, Seok E, Yang Y, Han G, Jo H, Yang H. Effects of Repeated Ovarian Stimulation on Ovarian Function and Aging in Mice. Dev Reprod. 2021;25(4):213\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eRizzuto I, Behrens RF, Smith LA. Risk of ovarian cancer in women treated with ovarian stimulating drugs for infertility. Cochrane Database Syst Rev. 2019;6(6):Cd008215.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003evan Leeuwen FE, Klip H, Mooij TM, van de Swaluw AM, Lambalk CB, Kortman M, Laven JS, Jansen CA, Helmerhorst FM, Cohlen BJ, et al. Risk of borderline and invasive ovarian tumours after ovarian stimulation for in vitro fertilization in a large Dutch cohort. Hum Reprod. 2011;26(12):3456\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSanner K, Conner P, Bergfeldt K, Dickman P, Sundfeldt K, Bergh T, Hagenfeldt K, Janson PO, Nilsson S, Persson I. Ovarian epithelial neoplasia after hormonal infertility treatment: long-term follow-up of a historical cohort in Sweden. Fertil Steril. 2009;91(4):1152\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBeebeejaun Y, Athithan A, Copeland TP, Kamath MS, Sarris I, Sunkara SK. Risk of breast cancer in women treated with ovarian stimulation drugs for infertility: a systematic review and meta-analysis. Fertil Steril. 2021;116(1):198\u0026ndash;207.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSilva Idos S, Wark PA, McCormack VA, Mayer D, Overton C, Little V, Nieto J, Hardiman P, Davies M. MacLean A B. Ovulation-stimulation drugs and cancer risks: a long-term follow-up of a British cohort. Br J Cancer. 2009;100(11):1824\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eZhang J, Lai Z, Shi L, Tian Y, Luo A, Xu Z, Ma X, Wang S. Repeated superovulation increases the risk of osteoporosis and cardiovascular diseases by accelerating ovarian aging in mice. Aging. 2018;10(5):1089\u0026ndash;102.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDong G, Guo Y, Cao H, Zhou T, Zhou Z, Sha J, Guo X, Zhu H. Long-term effects of repeated superovulation on ovarian structure and function in rhesus monkeys. Fertil Steril. 2014;102(5):1452-7.e1.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eYan P, Xu J, Zeng Y, Dong G, Cao H, Zheng M, Zhu H. Long-term effects of repeated superovulation on the uterus and mammary gland in rhesus monkeys. J Assist Reprod Genet. 2017;34(4):535\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Assisted reproduction, repeated COS, COS-IVF/ICSI, ovarian reserve, IVF/ICSI outcome","lastPublishedDoi":"10.21203/rs.3.rs-2189441/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2189441/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e It is ambiguous whether the multiple COS with supraphysiologic hormonal doses impact ovarian reserve functions or pregnancy outcomes. Furthermore, relevant retrospective studies are relatively scarce, chiefly in the last century, and ART techniques have seen innovation and improvement in the previous 20 years.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e The retrospective study included 45,555 IVF/ICSI fresh cycles enrolled between January 2015 and March 2021 were segregated into 5 different cycle cohorts. The participants were retrospectively grouped according to the number of repeated cycles. The primary observables symbolizing ovarian reserve function were antral follicle count (AFC) and anti-Müllerian hormone (AMH). We analyzed clinical pregnancy rate (CPR), live birth rates (LBR), and early miscarriage rate (EMR) to explore clinical pregnancy outcomes. Statistical methods were used for intra-group self-control comparisons, between-group comparisons, and logistic regression analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResult(s): \u003c/strong\u003eAmong the ovarian reserve function indicators, the AMH, AFC, basal FSH and basal LH exhibit no difference between groups (\u003cem\u003eP\u003c/em\u003e\u0026gt; 0.05). In different populations, there was a natural dropout trend for CPR (r = - 0.922, \u003cem\u003eP\u003c/em\u003e = 0.026) and LBR (r = - 0.920, \u003cem\u003eP\u003c/em\u003e = 0.027) with increasing number of population repetitions, while EMR displayed an increasing trend (r = 0.957, \u003cem\u003eP\u003c/em\u003e = 0.011). All differences between groups were statistically significant after logistic regression analysis. Intra-group analysis within same population revealed that, Cycle 2 in Group B (aOR = 8.29; 95% CI, 6.80-10.12; \u003cem\u003eP\u003c/em\u003e = 0.000), Cycle 3 in Group C (aOR = 6.05; 95% CI, 3.28-11.15; \u003cem\u003eP\u003c/em\u003e = 0.000) and Cycle 4 in Group D (aOR = 20.46; 95% CI, 3.05-137.24; \u003cem\u003eP\u003c/em\u003e = 0.002) had the highest CPR within each group; Cycle 2 in Group B and Cycle 3 in Group C had the highest LBR and lowest EMR within each group, and the differences did not reached statistical significance in the remaining groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion(s): \u003c/strong\u003eRepeated COS ( ≤ 5 times) does not disrupt ovarian reserve function. A raise in cycle number significantly increases CPR in the cohort of ≤ 4 repeated cycles, improves LBR, and reduces EMR in cohorts with ≤ 3 repeated cycles. Hence, patients are not advised to undergo ≥ 5 COS cycles.\u003c/p\u003e","manuscriptTitle":"Continue or quit? -- Recommendations for repeated controlled ovarian stimulation therapy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-10-27 20:03:46","doi":"10.21203/rs.3.rs-2189441/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"91026dc2-f434-4b89-a990-c87e1a27d9b8","owner":[],"postedDate":"October 27th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-11-02T10:59:33+00:00","versionOfRecord":[],"versionCreatedAt":"2022-10-27 20:03:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2189441","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2189441","identity":"rs-2189441","version":["v1"]},"buildId":"re_ckhLnmML6MCF96OHNJ","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}