Study on COQ Q10 for Ovulation and Pregnancy

 With age, the ovarian reserve function of women of childbearing age gradually decreases, and the rate of natural conception decreases, often requiring the use of assisted reproductive technology, such as in vitro fertilization and embryo transfer (IVF-ET). Patients with poor ovarian re- sponse (POR) often have poor response to gonadotropin (Gn) stimulation, resulting in unsatisfactory ovarian stimulation during IVF, fewer eggs and embryos available, or even no embryos available, increasing the cycle cancellation rate[1] . In order to improve the pregnancy rate, a variety of adjuvant drugs have been used in the field of reproduction and have achieved good results, coenzyme Q10 is one of them[2] .

 

Oxidative stress is an important factor in oocyte aging, increasing the rate of intracellular mitochondrial mutation, impairing function, and activating the apoptotic pathway. One of the important functions of mitochondria is to synthesize ATP, which supplies energy for the vital activities of tissue cells throughout the body. ATP is required for reproductive activities such as meiosis, ovulation, fertilization and embryo formation.

 

Oocyte maturation is often impaired and atresia is common in women with advanced infertility, and the number of available embryos is low, resulting in unsatisfactory pregnancy outcomes[3-5] . Coenzyme Q10 is a mitochondrial nutrient that transfers electrons and protons in the mitochondrial respiratory chain, maintains mitochondrial membrane potential, mitochondrial function and ATP synthesis, and ensures oocyte maturation, fertilization, embryo formation and implantation[6] . The present study was designed to investigate the effect of exogenous coenzyme Q10 supplementation on the outcome of assisted reproduction in POR, and to evaluate the efficacy of coenzyme Q10 in assisted reproduction.

 

1 Information and methodology

1. 1 General Information   

A total of 35 patients with POR who attended the Department of Reproductive Medicine of the Second Affiliated Hospital of Shandong University of Traditional Chinese Medicine from August 2021 to April 2022, whose transfer was canceled due to unavailability of embryos or implantation failure in the previous cycle and were pretreated with coenzyme Q10 before the next cycle were selected to be the study group (coenzyme Q10 group). A total of 35 patients of the same age group who underwent IVF for the first time with normal ovarian response were selected as the control group.

 

Inclusion criteria for the study group (Coenzyme Q10 group): (1) Meet the POR Poseidon criteria for group 4: Age ≥35 years, low ovarian reserve function (AFC<5, AMH<1.2ng/mL); (2) GnRH-a short regimen for the previous IVF cycle, with no transferable embryos, or failure to implant embryos in a fresh cycle; (3) Basal FSH<20U/L; (4) Infertility due to impaired gamete transport. 20U/L; (4) Infertility due to gamete transport disorders. Inclusion criteria for the control group: (1) age ≥ 35 years; (2) AFC ≥ 5, AMH ≥ 1.2 ng/mL; (3) basal FSH < 20 U/L; (4) infertility factor of impaired gamete transport. (2) AFC ≥5, AMH ≥1.2ng/mL; (3) infertility due to impaired gamete transport; (4) first time IVF fertilization.

 

Exclusion Criteria: (1) history of reproductive malformation or surgery affecting ovarian function; (2) adenomyosis, endometritis, untreated endometrial polyps, etc.; (3) combination of endocrine disorders, such as thyroid dysfunction, diabetes mellitus, etc.; (4) chromosomal abnormality in one or both spouses. Exclusion Criteria: (1) Failure to complete the required coenzyme Q10 intake; (2) Natural pregnancy during the treatment period; (3) Cancellation of the transplantation due to personal reasons. The study was approved by the Ethics Committee of the hospital. The patients gave their informed consent and signed a written consent form.

 

1.2 Pre-treatment drug regimen Coenzyme Q10 (Nengqilang, China Weicai) 10mg orally 3 times/d. Coenzyme Q10 (Nengqilang, China Weicai) 10mg orally, 3 times/d, for 2 months before the next COH cycle, and then until the HCG day after entering the cycle.

1. 3 COH Process   

A short GnRH-a regimen was used in both groups. Treprostinil acetate (GnRH-a, Dabiga, Pfizer, Germany) 0.1 mg was given from the 2nd day of menstruation, and recombinant human follicle stimulating hormone (rFSH, Gonadotrophin, Italy) 150 225U was given on the following day to promote ovulation, and the starting dose was determined according to the patient's age, body weight, basal hormone level, and ovarian response in the previous week.

 

When the diameter of one favorable follicle reaches 18mm, or the diameter of two or more follicles reaches 17mm, stop using GnRH-a and Gn. HCG (Lizhu Group Lizhu Pharmaceutical Factory) 5000 ~ 10000U trigger was given in the evening, and the eggs were retrieved under the guidance of transvaginal ultrasound after 35 ~ 36h. IVF was performed according to the operation standard, and the results of egg acquisition and fertilization were recorded. On the 3rd day after egg retrieval, the embryos were observed and scored according to the number of cells, the size and regularity of the cleavage bulb, the refractive index of the cytoplasm and the proportion of fragments, etc. They were classified into grades I to IV. Grade I and II embryos with cell number ≥6 and fragmentation <30% were regarded as high quality embryos. For those who need to continue culture, the formation of blastocysts was observed in the 5th~6th day after egg retrieval, and the quality of blastocysts was categorized into A, B and C according to the degree of expansion of blastocysts, the number of inner cell clusters and trophoblast cells, and blastocysts with D5 ≥ 3BB or D6 ≥ 4BB could be frozen or transplanted. For fresh cycle transplantation, 1~2 D3 high-quality embryos or blastocysts were selected for transplantation; for those who were not suitable for fresh cycle transplantation due to asynchronous endothelial development or other reasons, whole embryos were frozen and resuscitated for transplantation at a later date.

 

In the resuscitated patients, the endometrium was prepared by natural cycle, stimulation cycle or hormone replacement cycle, depending on the regularity of menstruation. After transplantation, all patients were given progesterone injection (Zhejiang Xianju) 60mg/d, and dexamethasone (Daflon, Oganon, Netherlands) 20mg/d until the day of blood β-HCG test. Blood β-HCG ≥ 10IU/L at 14d post-transplantation was determined as biochemical pregnancy, and the gestational sac with fetal heartbeat seen under transvaginal ultrasound at about 5 weeks post-transplantation was determined as clinical pregnancy. If pregnancy was confirmed, luteal support was continued until the 10th week of pregnancy.

 

1. 4 Observations and Definitions    

The AMH, AFC, basal FSH, total dose of Gn and days of stimulation, number of fertilized eggs, number of MⅡ eggs, number of fertilized eggs, number of high-quality embryos, MⅡ egg rate, fertilization rate, high-quality embryo rate, embryo implantation rate, clinical pregnancy rate, and early miscarriage rate were recorded in the two groups: MⅡ egg rate = number of MⅡ eggs/number of fertilized eggs×100%; fertilization rate = number of fertilized eggs/number of fertilized eggs × 100%; high-quality embryos = number of D3 quality embryos/D3 cleavage embryos × 100%; embryo implantation rate = number of confirmed gestational sacs under B ultrasonography/number of transferred embryos × 100%; and clinical pregnancy rate = number of fertilized eggs/number of transferred embryos × 100%. Fertilization rate = number of 2PN eggs/number of eggs fertilized × 100%; Eugenic rate = number of D3 high-quality embryos/number of D3 cleavage embryos × 100%; Embryo implantation rate = number of gestational sacs confirmed by ultrasound/number of embryos transferred × 100%; Clinical pregnancy rate = number of cycles in which the gestational sacs were confirmed by ultrasound/number of cycles in which the transfer was made × 100%; Early abortion rate = number of miscarried cycles by 12 weeks of gestation/number of clinical cycles in which pregnancy was carried to term × 100%.

 

1. 5 Statistical Processing    

SPSS27 . The SPSS27.0 software package was used. Data that conformed to normal distribution were expressed as x- ±s, and data that did not conform to normal distribution were expressed as median and interquartile range M(P25,P75 ), and comparisons between groups before and after treatment were made using the paired samples t-test, and comparisons between groups were made using the t-test for two independent samples. Categorical data were expressed as percentages [n(% )], and comparisons between groups were made using the x2 test. p<0.05 was considered a statistically significant difference. P<0.05 was regarded as statistically significant.

 

2 Results

2 . 1 Basic Information About the Patient

Five patients withdrew from the study, including 3 patients in the study group (2 patients did not take coenzyme Q10 as required and 1 patient moved out of the country and interrupted the treatment) and 2 patients in the control group (1 patient conceived naturally and 1 patient was delayed from entering the COH cycle due to severe anemia). There was no statistically significant difference in age, duration of infertility and BMI between the two groups (P>0.05) (Table 1). There was no statistically significant difference between the two groups in terms of age, duration of infertility and BMI (P>0.05) (Table 1).

 

2 . 2 Comparison of Ovarian Reserve Function    

The mean values of AMH and AFC before pretreatment in the study group were significantly lower than those in the control group, and the basal FSH was significantly higher than that in the control group, and the differences were statistically significant (P<0.05). The differences were statistically significant (P<0.05). After pretreatment with coenzyme Q10, AMH was not monitored; AFC increased 1.35 times compared with that before pretreatment, and the difference was statistically significant. The difference was statistically significant (P<0.001), but still significant. The difference was statistically significant (P<0.001), but still significantly lower than that of the control group (P = 0.002). 002); basal FSH was slightly lower than that before pretreatment, but significantly higher than that in the control group (P = 0.006). The basal FSH was slightly lower than that before pretreatment, but significantly higher than that of the control group (P = 0.006) (Table 1).

 

2 . 3 Gn Use, Ovarian Stimulation and Fertilization

Compared with the previous cycle, the amount of Gn and the number of days of stimulation were significantly lower in the study group after pretreatment (P = 0.041; P = 0.041; P = 0.041; P = 0.041; P = 0.041, respectively). 041;P = 0 . 005); the number of eggs obtained, the number of MⅡeggs, the number of fertilized eggs, the number of high-quality embryos, the rate of MⅡeggs, and the rate of fertilization were all significantly increased (P<0.001 or P=0.001). 001 or P = 0 . The number of MII eggs, the number of fertilized eggs, the number of quality embryos, the rate of MII eggs and the fertilization rate were all significantly increased (P<0.001 or P=0.001). Compared with the control group, there was no significant difference in the total dose of Gn and the number of days in the coenzyme Q10 group; the number of eggs obtained, the number of MII eggs, the number of fertilized eggs, the number of high-quality embryos and the fertilization rate were still significantly lower than those in the control group (P < 0.05). 05), and the rates of MⅡeggs and superior embryos were similar to those of the control group (Table 1).

Table 1 Patient's general condition, ovarian stimulation and embryological parameters

 

sports event	Coenzyme Q10 pretreatment (n=32)	Coenzyme Q10 before pretreatment	Control group (n=33)	t	P
(a person's) age	39. 84±2. 82	38. 61±3.00	1. 713	0. 092
Years of infertility	3. 72±2. 41	3. 30±2. 13	0. 737	0. 464
BMI	23. 44±4. 38	22.72±3.09	0. 769	0. 445
AMH	0. 95±0. 13	3. 22±1. 73	-7. 421	<0. 001
AFC	8.31±2.10 **	3. 53±0. 62	10.30±2.85	-3. 201	0. 002
Basic FSH	12. 24±2. 58	13. 46±2. 89	10.51±2.34	2. 837	0. 006
Gn Total dose	2005. 31±364.79 *	2139. 53±504. 66	2055±421.05	-0.508	0. 613
Gn Total days	9.31±0.93 *	9. 78±1. 34	9.00±1.15	1. 205	0. 233
clutch size	7.25±2.27 **	3. 44±0. 84	9.09±2.80	-2.906	0. 005
MII egg count	6.00±2.29 **	2. 03±0. 78	7. 73±2. 39	-2. 977	0. 004
fertilization number	4.84±1.95 **	1. 53±0. 80	6. 58±1. 99	-3.545	<0. 001
D3 Number of embryos	3. 84±2.03 **	0. 84±0. 85	5. 16±1. 66	-2. 815	0. 007
eukaryotic embryo number (i.e. number of embryos in a cell)	2. 28±1. 46 **	0. 47±0. 72	3. 06±1. 46	-2. 126	0. 038
MII egg rate	80. 21±14.89 **	59. 32±19. 78	86. 12±12.07	-1. 760	0. 083
fertilization rate	64.51±20.18 *	45.10±25.08	73. 38±12.97	-2. 114	0. 038
eukaryotic embryo rate	56. 23±24.12	58. 96±25. 47	-0.421	0. 675

*P<0.05 , **P<0.001 vs. before coenzyme Q10 pretreatment

2 . 4 Clinical Pregnancy Rate

The embryo implantation rate and clinical pregnancy rate in the coenzyme Q10 group were significantly higher than those before coenzyme Q10 treatment (24 . 44% vs 0; 30.77% vs 0), which was still lower than that of the control group. 77% vs 0), but still lower than the control group, the difference was not statistically significant (P>0.05). 05); early miscarriage rate was not significantly different from that of the control group (P = 0.05); early miscarriage rate was not significantly different from that of the control group (P = 0.05).

0 . 761) (Table 2).

Table 2 Embryo transfer and pregnancy outcome in two groups of patients

 

sports event	CoQ10 (n=26)	Control group (n=30)	x2	P
transplants
Freshness cycle (n)	18	22	0. 115	0. 735
Recovery cycle (n)	8	8
D3 day embryos (n)	15	16	0. 107	0. 743
Blastocysts (n)	11	14
Single (n)	7	5	0. 870	0. 351
2 (n) Pregnancy outcomes	19	25
Implantation rate (%)	24. 44 (11/45)	29. 09 (16/55)	0. 271	0. 603
Clinical pregnancy rate (%)	30. 77 (8/26)	40.00 (12/30)	0. 517	0. 472
Abortion rate (%)	12. 50 (1/8)	8.30 (1/12)	0. 093	0. 761

 

3 Discussion

Fertility declines significantly after the age of 35 years, and assisted reproductive technology has brought hope for conception to many infertile patients, but the pregnancy outcome of POR patients is still unsatisfactory. POR is mainly manifested by the decrease in ovarian reserve, reduced sensitivity to Gn, low number of good quality oocytes and embryos obtained, or even inability to enter the embryo transfer stage due to the absence of mature oocytes or usable embryos, which results in a low pregnancy and live birth rate [1]. This results in lower pregnancy and live birth rates [1].

 

In assisted reproduction, obtaining good quality oocytes and embryos, and optimizing endothelial tolerance are the two main factors that improve embryo implantation and pregnancy rates. In older women, oocytes tend to age, mitochondrial function declines, and ATP synthesis decreases. Hormone production, oocyte maturation and embryo formation are highly dependent on ATP function. Insufficient production of ATP can lead to oocyte growth stagnation, atresia, and reduced developmental potential, which in turn affects embryo formation and development, leading to a decrease in the implantation rate [7].

 

Coenzyme Q10 is a fat-soluble coenzyme widely found in the mitochondria of human tissues and cells[8] . Its main function is to transfer electrons from complex I and II to complex III in the mitochondrial respiratory chain and maintain the mitochondrial membrane potential difference[9] . At the same time, coenzymes have antioxidant effects, preventing protein and lipid peroxidation and avoiding oxidative stress damage[8] . Animal studies have shown that coenzyme Q10 can improve ovarian reserve, protect mitochondrial function and increase energy production[6] . Studies on DOR patients showed that the addition of coenzyme Q10 to VE could reduce basal FSH and E2, decrease the amount of Gn used during ovulation, and increase AFC[10] .

 

After the administration of coenzyme Q10 in this study group, the amount and duration of Gn were significantly reduced compared with the previous cycle, and there was no significant difference with the control group; the AFC was significantly increased, but still significantly lower than the control group. This showed that the ovarian response to stimulation was significantly improved by coenzyme Q10 pretreatment, narrowing the gap with the expected response of normal patients. In a study using Posidon standard group 3 as inclusion criteria, a significant reduction in Gn dosage and a significant increase in peak E2 levels were observed after coenzyme Q10 pretreatment[11] . A study in which patients with diminished ovarian reserve were pretreated with coenzyme Q10 for 3 menstrual cycles showed a significant decrease in basal FSH and a significant increase in AMH[12] . A retrospective study showed that supplementation with coenzyme Q10 significantly improved basal endocrine secretion and increased AMH and AFC in elderly women undergoing IVF-ET[13] .

 

In the present study, the number of eggs obtained, the number of MⅡeggs, the number of fertilized eggs, the number of superior embryos, the rate of MⅡeggs and the rate of fertilization in the coenzyme Q10 group were significantly increased compared with that of the previous cycle, and these changes prepared the conditions for a significant increase in the implantation rate of embryos and the pregnancy rate. It was hypothesized that coenzyme Q10 could not only increase the ovarian reserve, but also improve the quality of oocytes, thus increasing the fertilization rate and the rate of high-quality embryos.

 

Animal studies have shown that supplementation of coenzyme Q10 can increase the number of ovulation, reduce the level of ROS, and effectively counteract the age-induced decrease in ovarian reserve and reproductive aging[14] ; it can increase the rate of oocyte cleavage and embryo formation by increasing the content of ATP, and contribute to the expansion of blastocysts[15] .

 

Clinical studies have confirmed that the addition of coenzyme Q10 can increase the number of eggs and embryos, and reduce the cycle cancellation rate[11-12] . However, the data of the present study showed that the number of eggs acquired, the number of fertilized eggs, the number of eugenic embryos and the fertilization rate of the coenzyme Q10 group were still significantly lower than those of women of the same age group with normal expected ovarian response (P<0.05). 05).

 

There is no clear regulation on the use of coenzyme Q10 as adjuvant therapy in IVF-ET. In the present study, CoQ10 was administered as 10mg 3 times/d for two months of pretreatment, and then until the HCG day after entering the cycle. Xu et al. suggested that a two-month pretreatment period may be insufficient in clinical practice compared to animal studies where coenzyme Q10 is administered for approximately 1/4 of the life cycle[11] . Even though it may increase energy production, the ability to recover from oxygenation stress damage is still lacking[16] . It is therefore hypothesized that there may be more rational and effective dosing regimens, such as longer pretreatment times or dose adjustments, or combinations with other adjuvant therapies to improve ovarian function, to bring the ovarian reserve of patients with POR closer to that of women of the same age group with normal ovarian reserve function.

 

Clinical pregnancy rate was the primary pregnancy outcome, and live birth rate was not tracked. It has been suggested that coenzyme Q10 may reduce the aneuploidy rate and increase the pregnancy rate[16] . In the present study, the clinical pregnancy rate was significantly increased after coenzyme Q10 pretreatment (30.77% vs 0). 77% vs 0), which was lower than that of the control group, but the difference was not statistically significant; the difference in early miscarriage rate between the two groups was not significant. In one study, the addition of coenzyme Q10 to growth hormone significantly increased the embryo implantation rate and clinical pregnancy rate compared with the growth hormone only group[17] .

 

In the present study, the Poseidon criteria were used for the inclusion of POR patients, which stratified the age of patients on the basis of the Bologna criteria, so that the homogeneity of the enrolled patients was better than that of the Bologna criteria. In the control group, patients of the same age group who underwent IVF for the first time, without low ovarian reserve and with normal expected ovarian response, were selected.

 

This design not only allowed us to observe the changes in ovarian function and responsiveness, and pregnancy outcome of the study group after the use of coenzyme Q10, but also allowed us to compare the study group with the control group, and to understand the differences between the study group and the women who were expected to have a normal ovarian response after pretreatment. The greatest weakness of this study is the small sample size. The small sample size for the transfer cycle may have compromised the effectiveness of the evaluation because some patients had their cycles canceled due to unavailability of embryos. The number of patients enrolled should be increased in the design phase of the study, and the clinical pregnancy rate, persistence rate, and live birth rate should be tracked and compared in a large sample size trial to increase the credibility and persuasiveness of the results.

 

 

In addition, the selection of observation indicators is not comprehensive enough. The birth of a healthy newborn is the ultimate goal of both the reproductive physician and the patient, therefore, the live birth rate should be added to the main indicators of pregnancy outcome, and the birth defects of the newborn, maternal perinatal complications and other indicators should be followed up.

 

Coenzyme Q10 can improve ovarian responsiveness, increase the number of eggs obtained and the number of eugenic embryos in POR patients with poor IVF embryo quality or implantation failure in the past, increase the clinical pregnancy rate, and bring the ovarian function and pregnancy outcome of elderly POR patients close to the normal level of the same age group. However, there is still a gap between the number of eggs obtained and fertilization rate and that of patients with normal ovarian response. The efficacy of coenzyme Q10 in the treatment of elderly POR patients needs to be further observed and summarized in future studies with larger samples and more rigorous design.

 

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