Ovarian stimulation response and art outcomes among women with different infertility diagnoses undergoing ICSI with embryo pooling

Background: Infertility, affecting approximately 10-15% of reproductive-age couples, has multifactorial etiologies including endometriosis, polycystic ovary syndrome (PCOS), tubal factor infertility, male factor infertility, and unexplained infertility. Diminished ovarian reserve (DOR), often associated with poor ovarian response, poses significant challenges in assisted reproductive technology (ART), particularly in intracytoplasmic sperm injection (ICSI) cycles. Embryo pooling has emerged as a potential strategy to improve outcomes in patients with poor response by accumulating viable embryos across multiple stimulation cycles.Objective: This study aims to evaluate the efficacy of embryo pooling on pregnancy outcomes among women undergoing ICSI across different infertility etiologies, and to assess how these underlying conditions influence ovarian response, oocyte quality, and success rates in both fresh and frozen embryo transfer cycles.Methods: A retrospective study was conducted involving 220 women undergoing embryo pooling and ICSI at the Medical Health and Research Institute, Hyderabad. Participants were categorized into five etiological groups (n=44 each): endometriosis, PCOS, tubal factor, male factor, and unexplained infertility. Patients were further stratified based on age and AMH levels using the POSEIDON criteria. Ovarian stimulation protocols included GnRH agonist/antagonist, progestin-primed, mild stimulation, or natural cycles. Embryos were cryopreserved and pooled across multiple cycles, with subsequent transfer of one or more embryos based on availability and patient response. The primary outcome was biochemical pregnancy, followed by clinical pregnancy and live birth rates (LBRs).Results: Ovarian response and oocyte yield varied significantly by infertility etiology. PCOS patients exhibited the highest oocyte yield (?9 oocytes in 73%), while endometriosis cases were predominantly poor responders (<4 oocytes in 84%). Significant differences were also observed in baseline hormonal profiles and cycle characteristics. In fresh embryo transfers, the highest LBRs were noted in PCOS (46%) and unexplained infertility (43%), while male factor infertility had the lowest (34%). Frozen transfers demonstrated improved outcomes across most groups, with PCOS showing the highest LBR (48%) and CPR (57%). Endometriosis patients also benefited from frozen transfers, suggesting improved endometrial receptivity post-stimulation.Conclusion: Embryo pooling appears to enhance pregnancy outcomes in women undergoing ICSI, particularly in those with poor ovarian response or advanced reproductive age. Differences in infertility etiology significantly influence ovarian response, oocyte quality, and the effectiveness of fresh versus frozen embryo transfer strategies. Individualized treatment plans guided by the POSEIDON criteria and tailored stimulation protocols may optimize ART success.