Gonadotropin-releasing hormone antagonist protocol is associated with higher oocyte yield in young women at high risk...

To study whether the gonadotropin-releasing hormone (GnRH) antagonist protocol is associated with improved oocyte retrieval outcomes compared with the progestin-primed ovarian stimulation (PPOS) protocol in young women at high predicted risk for low oocyte yield.

Retrospective cohort study applying Bayesian analysis before and after propensity score matching, and risk-based stratified subgroup analysis.

A total of 2,068 women aged ≤35 years undergoing their first in vitro fertilization and intracytoplasmic sperm injection treatment cycles between January 2023 and April 2025, identified as high risk for low oocyte retrieval (predicted score ≥0.41) using a validated nomogram incorporating factors such as age, antimüllerian hormone levels, antral follicle count, basal follicle-stimulating hormone levels, and follicle-stimulating hormone:luteinizing hormone ratio.

Ovarian stimulation with either a GnRH antagonist protocol or a PPOS protocol, with protocol selection on the basis of clinical judgment and patient characteristics.

Incidence of low oocyte retrieval (<10 oocytes) and the number of oocytes retrieved.

Among 2,068 young women at high predicted risk for low oocyte yield, the GnRH antagonist protocol resulted in significantly better ovarian stimulation outcomes compared with the PPOS protocol. After propensity score matching, the antagonist group had a higher mean number of oocytes retrieved (8.3 vs. 5.3; Bayes factor in favor of the alternative hypothesis [BF₁₀] >10²⁸) and a higher oocyte retrieval rate (88.2% vs. 81.2%; BF₁₀ >10³). The incidence of low oocyte retrieval (<10 oocytes) was significantly lower in the antagonist group (65.2% vs. 86.0%; BF₁₀ >10¹⁹). No significant differences were observed in embryo quality or fertilization rates. Risk-based stratified analysis showed that the GnRH antagonist protocol significantly reduced the incidence of low oocyte retrieval in low-risk to midrisk groups (median odds ratio, 0.30-0.57, BF₁₀ up to 647.8), whereas in the highest-risk subgroup, PPOS showed a potential advantage.

The GnRH antagonist protocol is superior to PPOS in maximizing oocyte retrieval among young women at high predicted risk for low oocyte retrieval, highlighting the value of individualized risk-based stimulation strategies to improve clinical outcomes.