Dual Ovarian Stimulation in the Same IVF/ICSI Cycles for Treatment of Poor Ovarian Responders

This study is a prospective before \& after clinical trial to investigate the efficacy of double stimulations during both the follicular and luteal phases in patients with poor ovarian response undergoing IVF and intracytoplasmic sperm injection (ICSI) cycles. The study protocol is approved by the Ethics Committee (Institutional Review Board) of Royan institute. The study is conducted according to the Declaration of Helsinki for medical research. All participants provide informed consent after counseling for infertility treatments and routine IVF/ICSI programs. All the patients who diagnosed as poor ovarian responders (POR) based on the Bologna criteria are eligible for participation in this study. In order to define the poor response in IVF, at least two of the following three features must be present: (i) advanced maternal age or any other risk factor for POR; (ii) a previous POR; and (iii) an abnormal ovarian reserve test (ORT). Two episodes of POR after maximal stimulation are sufficient to define a patient as poor responder in the absence of advanced maternal age or abnormal ORT. Stage one of treatment protocol First stimulation performs by Clomiphene citrate (Ovumid®, Iran Hormones Company) 25 mg/day with co-treatment of Letrozole (Letrofem®, Iran Hormones Company) 2.5 mg/day are given from cycle day 3 onwards. Letrozole is only given for 4 days and clomiphene citrate is continuously used before the trigger day. Patients start to inject human menopausal gonadotrophin (HMG) (Menopur®, Ferring, Switzerland) 150 IU every other day beginning on cycle day 6. When one or two dominant follicles (18 mm in diameter) observed, the final stage of oocyte maturation will be induced with triptorelin 100 μg (Decapeptyl®; Ferring GmbH, Germany) follows by ibuprofen 600 mg (Ibuprofen-Najo® , Coated Tablets, Najo Company, Iran) is used on the day of oocyte maturation triggering and the day after. After the first oocyte retrieval, human menopausal gonadotrophin and letrozole