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Research Article | DOI: https://doi.org/10.31579/2578-8965/284
1Obstetrics and Gynaecology Department, Faculty of Medicine, Menoufia University, Shebin Elkom 32511, Menoufia, Egypt.
2Obstetrics and gynecology department, Shebin Elkom Teaching Hospital, Shebin Elkom 32511, Menoufia, Egypt.
3Obstetrics and Gynaecology Specialist, Fayoum General Hospital, Fayoum, Egypt.
*Corresponding Author: Sherif Sobhy Menshawy Khalifa, Obstetrics and Gynaecology Department, Faculty of Medicine, Menoufia University, Shebin Elkom 32511, Menoufia, Egypt.
Citation: Menshawy Khalifa SS, Ibrahim M. Elmaghraby, Abdalkareem Abdallatif MI, Khidre Bayoumi AM, (2025), Progesterone Primed Protocol Versus Antagonist Protocol in Polycystic Ovarian Syndrome in Freeze-All Cycles, J. Obstetrics Gynecology and Reproductive Sciences, 9(6) DOI:10.31579/2578-8965/284
Copyright: © 2025, Sherif Sobhy Menshawy Khalifa. This is an open-access article distributed under the terms of The Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 08 September 2025 | Accepted: 15 September 2025 | Published: 22 September 2025
Keywords: antagonist protocol; polycystic ovarian syndrome; In vitro fertilization; progesterone primed
Background: Women with polycystic ovary syndrome (PCOS) undergoing in vitro fertilization protocols are typically characterized by an increased number of oocytes retrieved. The oocytes are often of poor quality, leading to lower pregnancy rates, and higher miscarriage rates. Progestin-primed ovarian stimulation regimen was established for assisted reproduction. However, its feasibility and outcomes in PCOS patients need further evaluation. This work aims to evaluate the progesterone-primed protocol versus antagonist protocol in polycystic ovarian syndrome in a freeze-all cycle.
Methods: A randomized controlled trial was conducted on women with polycystic ovarian syndrome to evaluate the progesterone primed protocol versus antagonist protocol in polycystic ovarian syndrome in freeze-all cycles, at the Department of Obstetrics and Gynaecology (outpatient infertility clinic), Menoufia University Hospital, during the period time of the study.
Results: Chemical pregnancy rate was found in 122 (69.7%) of group A and in 145 (82.9%) of group B. Moreover, a clinical pregnancy rate was found in 112 (64.0%) of group A and 145 (82.9%) of group B. As well as early miscarriage was found in 20 (11.4%) of group A and in 50 (28.6%) of group B.
Conclusion: The progesterone protocol is comparable with the GnRH-ant protocol regarding oocyte/embryo yields and the probability of clinical pregnancy in PCOS patients, but the two regimens were distinct in the regulation of pituitary LH secretion. Also, Pituitary downregulation with progesterone as PPOS results in more oocytes retrieved and blastocysts to a GnRH antagonist protocol.
Polycystic ovarian syndrome (PCOS) is a common endocrine condition. Approximately 6.3–21.4% of women of reproductive age are afflicted by this condition [1]. In vitro fertilization (IVF) is a significant treatment for women with polycystic ovary syndrome (PCOS) [2]. Despite the increased quantity of oocytes in PCOS patients, low fertility rates, subpar oocyte quality, and elevated abortion rates remain significant concerns. Consequently, novel protocols are required to enhance therapeutic outcomes [3]. Currently, we are witnessing the use of 'freeze-all' procedures that preserve all oocytes or embryos, allowing for unrestricted ovarian stimulation, including the potential negative impacts of hormones on endometrial receptivity [4].
In recent years, gonadotropin-releasing hormone (GnRH) antagonist procedures have been increasingly utilized across diverse patient populations, including those with poor, normal, or elevated ovarian responses [5; 6]. The GnRH antagonist competitively binds to the GnRH receptor in the pituitary gland but fails to induce the production of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) [7]. GnRH antagonist treatments are categorized into two categories based on the timing of initiation. (i) fixed protocol, in which the GnRH antagonist commences at a predetermined period, often between days 5 and 6 of ovarian stimulation, and (ii) flexible protocol, in which the antagonist is provided daily after the leading follicles attain a diameter of 14 mm [8].
Recent research has concentrated on substituting GnRH analogs with progestins for the regulation of the LH surge, owing to the negative characteristics associated with GnRH analogs [9]. Progestin was considered a potential alternative for inhibiting premature LH surge during controlled ovarian stimulation [10]. Endogenous progesterone may impede the elevation of LH in the absence of a spontaneous LH surge during controlled ovarian stimulation in the luteal phase, according to certain studies [11]. Progesterone diminishes the pulsatility of GnRH from the hypothalamus, hence decreasing the release of LH linked to elevated estradiol levels [12].
In 2015, Dr. Yanping Kuang from China proposed the use of protest-primed ovarian stimulation (PPOS), an innovative ovarian stimulation protocol that combines progestin with exogenous gonadotrophins and regulates ovulation with a GnRH agonist, employing 'freeze-all' techniques. Rather than an elevation of progesterone as observed in conventional ovarian stimulation methods [13]. Progestin is employed as a substitute for the GnRH analogue in this innovative PPOS protocol to eliminate early LH during the follicular phase [14; 15]. Furthermore, progestin is administered orally and is readily accessible [16]. This innovative ovarian stimulation regimen has demonstrated effective prevention of a premature LH surge in cycles preceding embryo cryopreservation and does not impact on oocyte quality. The choice of appropriate progestin is crucial for the efficacy of the PPOS procedure [17]. This study is to assess the efficacy of the progesterone-primed treatment compared to the antagonist regimen in polycystic ovarian syndrome during freeze-all cycles.
Study design and patient grouping
A randomized controlled trial involved 350 women diagnosed with polycystic ovarian syndrome at the Department of Obstetrics and Gynecology (outpatient infertility clinic), Menoufia University Hospital, conducted from January 2023 to July 2025. A total of 350 women were categorized into two groups: Group A comprised 175 women undergoing the progesterone-primed treatment, whereas Group B consisted of 175 women undergoing the antagonist protocol. Women with PCOS were diagnosed according to the Rotterdam criteria (2003), which encompass polycystic ovaries, oligo-anovulation, and biochemical or clinical indicators of hyperandrogenism [18].
Ethical consideration
All procedures were conducted in compliance with the ethical norms established by the institutional committee. All procedures were conducted in accordance with the 1964 Declaration of Helsinki and its subsequent amendments, or equivalent ethical standards, as well as the ethical mandates of the institutional and/or national research committee. The study obtained clearance from the Ethical Committee of the Faculty of Medicine, Menoufia University (IRB approval number: 5/2-2330OBSGN3-1). The objectives and procedures of the study were elucidated to the participants, and written informed consent was acquired from all individuals following an explanation of the study's nature and scope.
Patients’ criteria
This study recruited women aged 18 to 40 years with polycystic ovarian syndrome. We excluded women having a history of intrauterine abnormalities (submucosal fibroma, uterine polyp, and intrauterine adhesions), severe endometriosis, systemic illnesses, and those whose husbands had azoospermia.
The study protocol
All individuals were administered with 150 subcutaneous doses of Cinnal-f starting on the second day of the cycle. Women in the progesterone-primed (PPOS) group received a 20 mg oral dose of Dydrogesterone starting on the second day of the cycle and continuing until the triggering day. Vaginal sonography was performed on all patients starting from the sixth day of their menstrual cycle. In the antagonist group, when the dominant follicles attained a size of 12–13 mm, 0.25 mg of Cetrotide was administered subcutaneously daily until the day of triggering. Serum LH, E2, and P were assessed when dominating follicles attained a size of 17 mm. The final triggering was executed via subcutaneous injection of Decapeptyl 0.2 mg and intramuscular injection of human chorionic gonadotropin (HCG) 1000 IU in both groups.
Oocyte Retrieval, Embryo Culture and Frozen-thawed Embryo Transfer
Oocyte retrieval was performed 36 hours later under anesthesia and ultrasound supervision. Oocyte insemination and embryo culture were conducted using established protocols. The assessment of embryo quality encompassed the quantity and regularity of blastomeres as well as the extent of fragmentation. Embryo morphology was evaluated by The Istanbul Consensus Workshop (2011). OHSS was delineated by an established classification approach [19]. All high-quality embryos (grades A and B) were cryopreserved via vitrification on the third day post-oocyte retrieval. The embryos of inferior quality were subjected to prolonged cultivation until reaching the blastocyst stage. At this stage, only blastocysts with superior morphology (grade exceeding 322) were cryopreserved. Embryos that were frozen and subsequently thawed, exhibiting over 50% intact blastomeres, were deemed to have successfully survived the freezing process. Only viable embryos were transplanted. All embryos were cryopreserved at the cleavage stage, and the frozen embryo transfer was conducted two months later. The preparation of the endometrium for frozen-thawed embryo transfer (FET) cycles was conducted as previously outlined [20]. Patients administered progesterone supplementation until the tenth week of gestation.
Outcomes of the study
The outcomes of the study in frozen cycles included early miscarriage, chemical pregnancy rate, and clinical pregnancy rate.
Statistical analysis
All data were aggregated and analyzed utilizing SPSS version 25 (SPSS Inc., Chicago, IL, USA). Continuous variables are expressed as means (± standard deviation (SD), whereas categorical variables are represented through relative frequency distributions and percentages. Categorical data were examined via the Chi-square test (Fisher or Monte Carlo), whereas descriptive variables were assessed by the Mann-Whitney U test, Student’s T-test, regression analysis, and Spearman correlation. Statistical significance was determined at p < 0.05.
Figure 1 illustrates a flowchart of the research population. Among the 369 women diagnosed with polycystic ovarian syndrome at Menoufia University Hospital. Nineteen patients were eliminated from the study: eight women rejected consent, and eleven women did not satisfy the inclusion criteria. Three hundred fifty women expressed willingness to participate and were allocated into two groups: Group A (progesterone), consisting of 175 participants, and Group B (antagonist), also comprising 175 participants (Figure 1).
Figure 1: Flowchart of women with polycystic ovarian syndrome.
There was no significant difference among the studied groups regarding age (P=0.052). While BMI and duration of infertility were significantly higher among group A (29.80± 2.92, 3.93±1.32) than group B (27.74± 3.72, 3.48±1.52) respectively (P<0.001). Also, there was significant difference among the studied groups regarding type and cause of infertility (P<0.001), 1ry type infertility was found in 97 (55.4%) of group A and in 154 (88.0%) of group B, while 2ry type infertility was found in 78 (44.6%) of group A and in 21 (12.0%) of group B. PCOS alone was found in 69 (39.4%) of group A and in 129 (73.7%) of group B, while PCOS combined was found in 106 (60.6%) of group A and in 46 (26.3%) of group B, (Table 1).
| Variable | Group A (n= 175) | Group B (n=175) | t | P value | ||
| N | % | N | % | |||
Age (years) Mean ± SD. Median (range) | 30.53±2.94 31.00 (23.00-36.00) | 30.09±2.13 30.00 (25.00-35.00) | 1.948 | 0.052 | ||
BMI (Kg/m2) Mean ± SD. Median (range) | 29.80± 2.92 30.00 (22.00-34.00) | 27.74± 3.72 28.00 (20.00-35.00) | 5.712 | <0> | ||
Duration of infertility (years) Mean ± SD. Median (range) | 3.93±1.32 4.00 (2.00-7.00) | 3.48±1.52 3.00 (2.00-8.00) | U=11559.000 | <0> | ||
Type of infertility 1ry 2ry | 97 78 | 55.4 44.6 | 154 21 | 88.0 12.0 | X2 =45.762 | <0> |
Cause of infertility PCOS alone PCOS combined | 69 106 | 39.4 60.6 | 129 46 | 73.7 26.3 | X2 =41.866 | <0> |
Table 1: Basic characteristics of the participants in two groups.
Progesterone (Group A), Antagonist (Group B), (Polycystic ovary syndrome (PCOS), Body mass index (BMI), Independent t test (t), Mann Whitney u test (U), Chi square test (X2), *Significant.
Additionally, number of oocytes, number of fertilized oocytes 1 and number of blastocysts were significantly higher among group A (20.01± 3.18, 15.39± 2.96, 12.99± 8.78) than group B (16.89±2.69, 12.46±2.73, 12.46±2.73) respectively (P<0.001). While number of fertilized oocytes 2 and final
endometrium thickness before start of progesterone were significantly lower among group A (1.57± 0.50, 10.19±0.91) than group B (1.98±0.15, 10.72±0.92) respectively (P<0.001). In our study, A notable disparity existed among the examined groups for chemical pregnancy rate, clinical pregnancy rate, and early miscarriage (P<0.001). The chemical pregnancy rate was observed in 122 (69.7%) of group A and in 145 (82.9%) of group B. Furthermore, the clinical pregnancy rate was observed in 112 (64.0%) of group A and in 145 (82.9%) of group B. Early miscarriage occurred in 20 (11.4%) of group A and in 50 (28.6%) of group B, (Table 2).
| Variable | Group A (n= 175) | Group B (n=175) | U | P value |
Number of oocytes Mean ± SD. Median (range) | 20.01± 3.18 20.00 (10.00-28.00) | 16.89±2.69 17.00 (12.00-24.00) | 6912.000 | <0> |
Number of fertilized oocyte1 Mean ± SD. Median (range) | 15.39± 2.96 16.00 (8.00-24.00) | 12.46±2.73 12.00 (8.00-19.00) | 7287.000 | <0> |
Number of fertilized oocyte2 Mean ± SD. Median (range) | 1.57± 0.50 2.00 (1.00-2.00) | 1.98±0.15 2.00 (1.00-2.00) | 9100.000 | <0> |
Number of blastocysts Mean ± SD. Median (range) | 12.99± 8.78 12.00 (5.00-89.00) | 12.46±2.738.00 (4.00-13.00) | 2986.500 | <0> |
Final endometrium thickness before start of progesterone Mean ± SD. Median (range) | 10.19±0.91 10.00 (0.00-12.00) | 10.72±0.92 10.50 (9.50-12.00) | 11315.000 | <0> |
| Outcomes in frozen cycles | X2 | P value | ||
| Chemical pregnancy rate | 122 (69.7%) | 145 (82.9%) | 8.355 | <0> |
| Clinical pregnancy rate | 112 (64%) | 145 (82.9%) | 15.947 | <0> |
| Early miscarriage | 20 (11.4%) | 50 (28.6%) | 16.071 | <0> |
Table 2: Fertilized oocytes, blastocytes and endometrium thickness before start of progesterone and Outcomes in frozen cycles.
Progesterone (Group A), Antagonist (Group B), Mann Whitney u test (U), Chi square test (X2), *Significant.
Among group A and B, there was no significant relation among types of infertility regarding chemical pregnancy rate, clinical pregnancy rate and
early miscarriage (P>0.05), (Figure 2). Among group A and B, there was no significant relation among causes of infertility regarding chemical pregnancy rate, clinical pregnancy rate and early miscarriage (P>0.05), (Figure 3).
Figure 2: Outcomes in frozen cycles in relation to type of infertility among the studied groups.
Figure 3: Outcomes in frozen cycles in relation to cause of infertility among the studied groups.
Regression analysis indicated that BMI, duration of infertility and final endometrium thickness before start of progesterone were the most factors affected chemical pregnancy rate (P<0.05). While other parameters didn’t show any significant affection on chemical pregnancy rate (P>0.05). Regression analysis indicated that BMI, duration of infertility, number of blastocysts and final endometrium thickness before start of progesterone were the most factors affected clinical pregnancy rate (P<0.05). While other parameters didn’t show any significant affection on clinical pregnancy rate (P>0.05). Regression analysis indicated that cause of infertility and number of blastocysts were the most factors affected by early miscarriage rate (P<0.05). While other parameters didn’t show any significant affection on early miscarriage rate (P>0.05), (Table 3).
| Chemical pregnancy rate | B | Std. Error | Wald | Sig. | Exp(B) | 95% CI | |
| Lower | Upper | ||||||
| Age (years) | -0.038 | 0.056 | 0.461 | 0.497 | 0.963 | 0.86 | 1.07 |
| BMI (Kg/m2) | -0.099 | 0.044 | 5.181 | 0.023* | 0.906 | 0.83 | 0.99 |
| Duration of infertility (years) | 0.212 | 0.110 | 3.727 | 0.048* | 1.236 | 1.00 | 1.53 |
| Type of infertility | 0.092 | 0.300 | 0.095 | 0.759 | 1.097 | 0.61 | 1.98 |
| Cause of infertility | -0.053 | 0.275 | 0.037 | 0.847 | 0.948 | 0.55 | 1.63 |
| Number of oocytes | 0.027 | 0.049 | 0.304 | 0.581 | 1.028 | 0.93 | 1.13 |
| Number of fertilized oocyte1 | -0.097 | 0.051 | 3.707 | 0.054 | 0.907 | 0.82 | 1.00 |
| Number of blastocysts | 0.004 | 0.022 | 0.028 | 0.866 | 1.004 | 0.96 | 1.05 |
| Number of fertilized oocyte2 | -0.031 | 0.335 | 0.009 | 0.925 | 0.969 | 0.50 | 1.87 |
| Final endometrium thickness before start of progesterone | 0.352 | 0.160 | 4.850 | 0.028* | 1.421 | 1.04 | 1.94 |
| Clinical pregnancy rate | |||||||
| Age (years) | -0.092 | 0.056 | 2.726 | 0.099 | 0.912 | 0.82 | 1.02 |
| BMI (Kg/m2) | -0.087 | 0.043 | 4.133 | 0.042* | 0.917 | 0.84 | 1.00 |
| Duration of infertility (years) | 0.281 | 0.110 | 6.503 | 0.011* | 1.325 | 1.07 | 1.65 |
| Type of infertility | 0.071 | 0.296 | 0.057 | 0.811 | 1.073 | 0.60 | 1.92 |
| Cause of infertility | 0.057 | 0.273 | 0.043 | 0.836 | 1.058 | 0.62 | 1.81 |
| Number of oocytes | 0.081 | 0.052 | 2.492 | 0.114 | 1.085 | 0.98 | 1.20 |
| Number of fertilized oocyte1 | -0.078 | 0.053 | 2.230 | 0.135 | 0.925 | 0.83 | 1.03 |
| Number of blastocysts | -0.106 | 0.052 | 4.094 | 0.043* | 0.900 | 0.81 | 1.00 |
| Number of fertilized oocyte2 | 0.037 | 0.331 | 0.013 | 0.911 | 1.038 | 0.54 | 1.99 |
| Final endometrium thickness before start of progesterone | 0.313 | 0.155 | 4.098 | 0.043* | 1.368 | 1.01 | 1.85 |
| Early miscarriage | |||||||
| Age (years) | -0.012 | 0.065 | 0.036 | 0.850 | 0.988 | 0.87 | 1.12 |
| BMI (Kg/m2) | -0.007 | 0.044 | 0.028 | 0.868 | 0.993 | 0.91 | 1.08 |
| Duration of infertility (years) | 0.249 | 0.106 | 5.533 | 0.019 | 1.283 | 1.04 | 1.58 |
| Type of infertility | -0.045 | 0.363 | 0.016 | 0.900 | 0.956 | 0.47 | 1.95 |
| Cause of infertility | -0.974 | 0.353 | 7.603 | 0.006* | 0.378 | 0.19 | 0.75 |
| Number of oocytes | 0.061 | 0.057 | 1.129 | 0.288 | 1.063 | 0.95 | 1.19 |
| Number of fertilized oocyte1 | -0.022 | 0.055 | 0.152 | 0.696 | 0.979 | 0.88 | 1.09 |
| Number of blastocysts | -0.142 | 0.069 | 4.250 | 0.039* | 0.868 | 0.76 | 0.99 |
| Number of fertilized oocyte2 | 0.186 | 0.448 | 0.173 | 0.678 | 1.205 | 0.50 | 2.90 |
| Final endometrium thickness before start of progesterone | 0.189 | 0.179 | 1.115 | 0.291 | 1.208 | 0.85 | 1.72 |
Table 3: Regression analysis for the parameters affecting pregnancy rate (chemical, clinical) and Early miscarriage.
Body mass index (BMI), Confidence Interval (CI), *Significant.
In group A, no significant correlation was observed between chemical pregnancy rate, clinical pregnancy, and early miscarriage with age, BMI, duration of infertility, type of infertility, cause of infertility, number of oocytes, number of fertilized oocytes 1, number of blastocysts, number of fertilized oocytes 2, and final endometrial thickness before the initiation of progesterone in the examined cases (P>0.05). In group B, no significant correlation was observed between age, duration of infertility, type of infertility, cause of infertility, number of oocytes, number of fertilized oocytes, number of blastocysts, and final endometrial thickness before the initiation of progesterone, with the chemical and clinical pregnancy rates (P>0.05). A substantial positive link existed between the chemical pregnancy rate, BMI, and the number of fertilized oocytes (P<0.05). In group B, no significant correlation was observed between the early miscarriage rate and age, BMI, type of infertility, cause of infertility, number of oocytes, number of fertilized oocytes 1, number of fertilized oocytes 2, and final endometrial thickness before the initiation of progesterone in the examined cases (P>0.05). A substantial negative connection existed between the rate of early miscarriage and the length of infertility (P<0.001). Additionally, a strong positive connection was seen between the early miscarriage rate and the quantity of blastocysts (P=0.001), (Table 4).
| Correlation test | Among group A | Among group B | |||||
| Chemical pregnancy rate | Clinical pregnancy rate | Early miscarriage | Chemical pregnancy rate | Clinical pregnancy rate | Early miscarriage | ||
| Age (years) | rs | 0.005 | 0.075 | 0.136 | -0.031 | -0.031 | -0.117 |
| P value | 0.943 | 0.322 | 0.072 | 0.684 | 0.684 | 0.122 | |
| BMI (Kg/m2) | rs | -0.118 | -0.132 | -0.020 | 0.270 | 0.270 | -0.046 |
| P value | 0.121 | 0.082 | 0.796 | <0.001* | <0.001* | 0.547 | |
| Duration of infertility/ years | rs | -0.103 | -0.115 | 0.114 | -0.041 | -0.041 | -0.317 |
| P value | 0.174 | 0.129 | 0.132 | 0.590 | 0.590 | <0.001* | |
| Type of infertility | rs | -0.066 | -0.074 | -0.039 | 0.019 | 0.019 | 0.078 |
| P value | 0.388 | 0.332 | 0.606 | 0.806 | 0.806 | 0.306 | |
| Cause of infertility | rs | -0.054 | -0.053 | 0.078 | 0.004 | 0.004 | 0.148 |
| P value | 0.482 | 0.489 | 0.307 | 0.959 | 0.959 | 0.051 | |
Number of oocytes
| rs | -0.106 | -0.140 | -0.141 | 0.067 | 0.067 | 0.023 |
| P value | 0.163 | 0.065 | 0.063 | 0.381 | 0.381 | 0.770 | |
| Number of fertilized oocytes 1 | rs | -0.073 | -0.084 | -0.015 | 0.198 | 0.198 | 0.022 |
| P value | 0.335 | 0.270 | 0.845 | 0.009* | 0.009* | 0.777 | |
| Number of blastocysts | rs | -0.050 | 0.008 | -0.068 | 0.102 | 0.102 | 0.255 |
| P value | 0.515 | 0.914 | 0.374 | 0.179 | 0.179 | 0.001* | |
| Number of fertilized oocytes 2 | rs | 0.118 | 0.120 | 0.016 | -0.336 | -0.336 | -0.097 |
| P value | 0.118 | 0.113 | 0.838 | <0.001* | <0.001* | 0.203 | |
| Final endometrium thickness before start of progesterone | rs | -0.103 | -0.058 | -0.064 | -0.103 | -0.103 | -0.052 |
| P value | 0.175 | 0.444 | 0.402 | 0.176 | 0.176 | 0.497 | |
Table 4: Correlation coefficient between pregnancy and early miscarriage rates with the studied variables among the studied groups.
Progesterone (Group A), Antagonist (Group B), Body mass index (BMI), *Significant.
Polycystic ovarian syndrome (PCOS) is a prominent condition and a frequent contributor to infertility, affecting over 80% of women with anovulatory infertility [21, 22]. Individuals with PCOS exhibit an elevated risk for ovarian hyperstimulation syndrome (OHSS), necessitating meticulous risk control techniques. Patients must be appreciated of the possible adverse effects of ovulation induction medications, the risks associated with IVF on the fetus, and the likelihood of multiple gestations [23-25]. The protocol of the Progestin-primed ovarian stimulation (PPOS) is an innovative ovarian stimulation regimen utilizing a freeze-all method, employing progestin as a substitute for a GnRH analog to inhibit premature LH surges during the follicular phase [13, 26]. Since 2016, it has been extensively utilized in patients undergoing IVF, demonstrating favorable IVF outcomes [27, 28]. Nevertheless, no studies compared the efficacy of the PPOS protocol and the GnRH-antagonist regimen in patients with PCOS in Egypt. This study intends to compare the progesterone-primed regimen with the antagonist protocol in polycystic ovarian syndrome during freeze-all cycles.
In our investigation, the quantity of fertilized oocytes and blastocysts was markedly greater in group A compared to group B. The quantity of fertilized oocytes and the ultimate endometrial thickness before the initiation of progesterone were considerably lower in group A compared to group B. According to our research, Xiao et al. [29] showed that the number of oocytes retrieved in the PPOS protocol group markedly diminished in comparison to the GnRH antagonist protocol group. The PPOS regimen was linked to a reduced likelihood of mild-to-moderate ovarian hyperstimulation syndrome (OHSS). Despite the GnRH antagonist treatment yielding a greater number of oocytes, the viable embryo rate per retrieved oocyte was comparable to that of the PPOS technique. The PPOS regimen was linked to a reduced likelihood of mild-to-moderate ovarian hyperstimulation syndrome (OHSS). While the GnRH antagonist technique yielded a greater number of oocytes, the viable embryo rate per retrieved oocyte was comparable to that of the PPOS protocol. The GnRH antagonist treatment group had a considerably larger quantity of cryopreserved embryos. The cryopreserved embryos in the PPOS protocol cohort were sufficient for 2 to 3 transfers (1 to 3 embryos per transfer). The cumulative pregnancy rate per patient was comparable in two further trials conducted by Fatemi et al. [30] and Bosch et al. [31]. Our findings align with Kuang et al. [27], who compared the PPOS procedure with the GnRH agonist short protocol, demonstrating that the rates of oocyte retrieval, mature oocytes, fertilization, and cleaved embryos were comparable between the two groups. The FET results demonstrated that embryos derived from the PPOS procedure exhibited comparable developmental potential to those from the GnRH agonist short protocol.
Our study revealed a notable increase in the number of retrieved oocytes in the dual stimulation group compared to the double follicular stimulation group (8 versus 6 oocytes). Glujovsky et al. [32] examined two randomized controlled trials, and one pilot study investigated dual stimulation in poor ovarian responders compared to a single wave of the usual antagonist strategy. The dual stimulation nearly increased the number of ripe oocytes. We observed a trend indicating an increase in mature oocytes retrieved from the dual stimulation protocol, although this difference was statistically insignificant (6 versus 4.5 oocytes). Additionally, there was a significantly higher number of retrieved oocytes following dual stimulation compared to conventional stimulation. It is imperative to emphasize that we have juxtaposed the dual stimulation technique with two waves of antagonist follicular stimulation. Their conclusion indicates that luteal stimulation in poor responders may be more efficacious than follicular stimulation, as will be discussed further. Iwami et al. [33] discovered no significant differences in stimulation duration, mature oocyte count, fertilization rate, or embryo quantity, aligning with our findings. Cui et al. [34] identified a statistically significant increase in the number of embryos in the progestin-primed treatment. Concerning pregnancy outcomes, both trials revealed no disparity in continued pregnancy or live birth rates.
Our work contradicts the findings of Cui et al. [34], who compared progestin-primed stimulation with the antagonist procedure. No significant variations were seen in the total days of stimulation, the total dosage of gonadotropins, or the number of mature oocytes between the two procedures. determined that progestin-primed dual stimulation is a legitimate alternative for patients with diminished ovarian reserve. Likewise, Begueria et al. [35] indicated that there were no differences in the quantity of mature oocytes, duration of stimulation, fertilization rate, or embryo quality between the two treatments. The number of oocytes, the count of fertilized oocytes, and the number of blastocysts were considerably more in the progesterone group compared to the antagonist group. The quantity of fertilized oocytes and the ultimate endometrial thickness before the initiation of progesterone were considerably lower in group A compared to group B. Zhu et al. [36] reported that the quantities of retrieved oocytes, MII oocytes, fertilized oocytes, cleaved embryos, and viable embryos in the progesterone protocol exceeded those in the GnRH-ant regimen, however, no statistical significance was seen. Furthermore, the rates of oocyte retrieval and fertilization were markedly elevated in the progesterone treatment. No instances of moderate or severe OHSS were observed in our investigation. In addition to the "freeze-all" technique, alternative preventative methods, such as vaginal birth, administration of the dopamine agonist cabergoline, and the utilization of GnRH agonist in place of human chorionic gonadotropin for triggering, contribute to the prevention of OHSS. The results validated that the progesterone protocol may serve as a viable alternative regimen for PCOS patients undergoing IVF/ICSI therapies with embryo cryopreservation. Eftekhar et al. (2) discovered that the maturity rate of oocytes in the PPOS group was significantly inferior to that in the antagonist group. Furthermore, the fertilization rate decreased in the PPOS group. No notable variations were observed in the quantity of harvested oocytes or the rate of ongoing pregnancies. Nevertheless, a substantial dosage of HMG was administered in the PPOS group. Considering the specific risk of OHSS, two instances were documented in the short protocol group compared to none in the PPOS group. Furthermore, Jawed et al. [37] found that the oocyte maturity rate is a predictor of the fertilization rate; hence, a diminished oocyte maturity rate may correlate with a reduced oocyte fertilization rate.
Our investigation demonstrated a considerable disparity among the examined groups for chemical pregnancy rate, clinical pregnancy rate, and early miscarriage. According to our study, Eftekhar et al. (2) showed that the clinical pregnancy rate for FET in PPOS was lower, at 14.6% compared to 29.9%. The implantation rate was reduced in the PPOS group. There was a notable disparity among the examined groups for the rates of chemical pregnancy, clinical pregnancy, and early miscarriage. The chemical pregnancy rate was observed in 122 individuals from the progesterone group and in 145 individuals from the antagonist group. Furthermore, the clinical pregnancy rate was observed in 112 (64.0%) of group A and 145 (82.9%) of group B. Early miscarriage occurred in 20 (11.4%) of group A and 50 of group B. Furthermore, it was determined that there was no significant correlation between the causes of infertility and the rates of chemical pregnancy, clinical pregnancy, and early miscarriage among the progesterone and antagonist groups. Fatemi et al. (30) discovered that while the number of cryopreserved embryos was much greater in the GnRH antagonist treatment group, the cryopreserved embryos in the PPOS protocol group were sufficient for 2–3 transfers (1–3 embryos per transfer). The aggregate pregnancy rate per patient was comparable. In contrast, Kuang et al. (13) performed a primary randomized trial on PPOS. Medroxyprogesterone acetate was incorporated into gonadotropin-induced stimulation during the follicular phase, and this treatment was compared with the conventional short regimen. They established that pregnancy, implantation, and loss rates were not significantly different across the groups. These findings align with the conclusions of Iwami et al. [33], which indicated that the frequencies of continuing and clinical pregnancies were comparable in both groups. This may result from the limited sample size of our patients and varying situations.
In conclusion, the progesterone protocol is comparable with the GnRH-ant protocol regarding oocyte/embryo yields and the probability of clinical pregnancy in PCOS patients, but the two regimens were distinct in the regulation of pituitary LH secretion. Also, Pituitary downregulation with progesterone as PPOS results in more oocytes retrieved and blastocysts to a GnRH antagonist protocol.
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Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
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The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
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Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
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Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
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I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
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I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
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Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
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Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
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My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
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I would like to express my sincere gratitude for the support and efficiency provided by the editorial office throughout the publication process of my article, “Delayed Vulvar Metastases from Rectal Carcinoma: A Case Report.” I greatly appreciate the assistance and guidance I received from your team, which made the entire process smooth and efficient. The peer review process was thorough and constructive, contributing to the overall quality of the final article. I am very grateful for the high level of professionalism and commitment shown by the editorial staff, and I look forward to maintaining a long-term collaboration with the International Journal of Clinical Case Reports and Reviews.
To Dear Erin Aust, I would like to express my heartfelt appreciation for the opportunity to have my work published in this esteemed journal. The entire publication process was smooth and well-organized, and I am extremely satisfied with the final result. The Editorial Team demonstrated the utmost professionalism, providing prompt and insightful feedback throughout the review process. Their clear communication and constructive suggestions were invaluable in enhancing my manuscript, and their meticulous attention to detail and dedication to quality are truly commendable. Additionally, the support from the Editorial Office was exceptional. From the initial submission to the final publication, I was guided through every step of the process with great care and professionalism. The team's responsiveness and assistance made the entire experience both easy and stress-free. I am also deeply impressed by the quality and reputation of the journal. It is an honor to have my research featured in such a respected publication, and I am confident that it will make a meaningful contribution to the field.
"I am grateful for the opportunity of contributing to [International Journal of Clinical Case Reports and Reviews] and for the rigorous review process that enhances the quality of research published in your esteemed journal. I sincerely appreciate the time and effort of your team who have dedicatedly helped me in improvising changes and modifying my manuscript. The insightful comments and constructive feedback provided have been invaluable in refining and strengthening my work".
I thank the ‘Journal of Clinical Research and Reports’ for accepting this article for publication. This is a rigorously peer reviewed journal which is on all major global scientific data bases. I note the review process was prompt, thorough and professionally critical. It gave us an insight into a number of important scientific/statistical issues. The review prompted us to review the relevant literature again and look at the limitations of the study. The peer reviewers were open, clear in the instructions and the editorial team was very prompt in their communication. This journal certainly publishes quality research articles. I would recommend the journal for any future publications.
Dear Jessica Magne, with gratitude for the joint work. Fast process of receiving and processing the submitted scientific materials in “Clinical Cardiology and Cardiovascular Interventions”. High level of competence of the editors with clear and correct recommendations and ideas for enriching the article.
We found the peer review process quick and positive in its input. The support from the editorial officer has been very agile, always with the intention of improving the article and taking into account our subsequent corrections.
My article, titled 'No Way Out of the Smartphone Epidemic Without Considering the Insights of Brain Research,' has been republished in the International Journal of Clinical Case Reports and Reviews. The review process was seamless and professional, with the editors being both friendly and supportive. I am deeply grateful for their efforts.
To Dear Erin Aust – Editorial Coordinator of Journal of General Medicine and Clinical Practice! I declare that I am absolutely satisfied with your work carried out with great competence in following the manuscript during the various stages from its receipt, during the revision process to the final acceptance for publication. Thank Prof. Elvira Farina
Dear Jessica, and the super professional team of the ‘Clinical Cardiology and Cardiovascular Interventions’ I am sincerely grateful to the coordinated work of the journal team for the no problem with the submission of my manuscript: “Cardiometabolic Disorders in A Pregnant Woman with Severe Preeclampsia on the Background of Morbid Obesity (Case Report).” The review process by 5 experts was fast, and the comments were professional, which made it more specific and academic, and the process of publication and presentation of the article was excellent. I recommend that my colleagues publish articles in this journal, and I am interested in further scientific cooperation. Sincerely and best wishes, Dr. Oleg Golyanovskiy.
Dear Ashley Rosa, Editorial Coordinator of the journal - Psychology and Mental Health Care. " The process of obtaining publication of my article in the Psychology and Mental Health Journal was positive in all areas. The peer review process resulted in a number of valuable comments, the editorial process was collaborative and timely, and the quality of this journal has been quickly noticed, resulting in alternative journals contacting me to publish with them." Warm regards, Susan Anne Smith, PhD. Australian Breastfeeding Association.
Dear Jessica Magne, Editorial Coordinator, Clinical Cardiology and Cardiovascular Interventions, Auctores Publishing LLC. I appreciate the journal (JCCI) editorial office support, the entire team leads were always ready to help, not only on technical front but also on thorough process. Also, I should thank dear reviewers’ attention to detail and creative approach to teach me and bring new insights by their comments. Surely, more discussions and introduction of other hemodynamic devices would provide better prevention and management of shock states. Your efforts and dedication in presenting educational materials in this journal are commendable. Best wishes from, Farahnaz Fallahian.
Dear Maria Emerson, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews, Auctores Publishing LLC. I am delighted to have published our manuscript, "Acute Colonic Pseudo-Obstruction (ACPO): A rare but serious complication following caesarean section." I want to thank the editorial team, especially Maria Emerson, for their prompt review of the manuscript, quick responses to queries, and overall support. Yours sincerely Dr. Victor Olagundoye.
Dear Ashley Rosa, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews. Many thanks for publishing this manuscript after I lost confidence the editors were most helpful, more than other journals Best wishes from, Susan Anne Smith, PhD. Australian Breastfeeding Association.
Dear Agrippa Hilda, Editorial Coordinator, Journal of Neuroscience and Neurological Surgery. The entire process including article submission, review, revision, and publication was extremely easy. The journal editor was prompt and helpful, and the reviewers contributed to the quality of the paper. Thank you so much! Eric Nussbaum, MD
Dr Hala Al Shaikh This is to acknowledge that the peer review process for the article ’ A Novel Gnrh1 Gene Mutation in Four Omani Male Siblings, Presentation and Management ’ sent to the International Journal of Clinical Case Reports and Reviews was quick and smooth. The editorial office was prompt with easy communication.
Dear Erin Aust, Editorial Coordinator, Journal of General Medicine and Clinical Practice. We are pleased to share our experience with the “Journal of General Medicine and Clinical Practice”, following the successful publication of our article. The peer review process was thorough and constructive, helping to improve the clarity and quality of the manuscript. We are especially thankful to Ms. Erin Aust, the Editorial Coordinator, for her prompt communication and continuous support throughout the process. Her professionalism ensured a smooth and efficient publication experience. The journal upholds high editorial standards, and we highly recommend it to fellow researchers seeking a credible platform for their work. Best wishes By, Dr. Rakhi Mishra.
Dear Jessica Magne, Editorial Coordinator, Clinical Cardiology and Cardiovascular Interventions, Auctores Publishing LLC. The peer review process of the journal of Clinical Cardiology and Cardiovascular Interventions was excellent and fast, as was the support of the editorial office and the quality of the journal. Kind regards Walter F. Riesen Prof. Dr. Dr. h.c. Walter F. Riesen.
Dear Ashley Rosa, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews, Auctores Publishing LLC. Thank you for publishing our article, Exploring Clozapine's Efficacy in Managing Aggression: A Multiple Single-Case Study in Forensic Psychiatry in the international journal of clinical case reports and reviews. We found the peer review process very professional and efficient. The comments were constructive, and the whole process was efficient. On behalf of the co-authors, I would like to thank you for publishing this article. With regards, Dr. Jelle R. Lettinga.
Dear Clarissa Eric, Editorial Coordinator, Journal of Clinical Case Reports and Studies, I would like to express my deep admiration for the exceptional professionalism demonstrated by your journal. I am thoroughly impressed by the speed of the editorial process, the substantive and insightful reviews, and the meticulous preparation of the manuscript for publication. Additionally, I greatly appreciate the courteous and immediate responses from your editorial office to all my inquiries. Best Regards, Dariusz Ziora
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Dear Clarissa Eric, Editorial Coordinator, Journal of Clinical Case Reports and Studies, Auctores Publishing LLC, USA Office: +1-(302)-520-2644. I would like to express my sincere appreciation for the efficient and professional handling of my case report by the ‘Journal of Clinical Case Reports and Studies’. The peer review process was not only fast but also highly constructive—the reviewers’ comments were clear, relevant, and greatly helped me improve the quality and clarity of my manuscript. I also received excellent support from the editorial office throughout the process. Communication was smooth and timely, and I felt well guided at every stage, from submission to publication. The overall quality and rigor of the journal are truly commendable. I am pleased to have published my work with Journal of Clinical Case Reports and Studies, and I look forward to future opportunities for collaboration. Sincerely, Aline Tollet, UCLouvain.
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Dear Maria Emerson, Editorial Coordinator, we have deeply appreciated the professionalism demonstrated by the International Journal of Clinical Case Reports and Reviews. The reviewers have extensive knowledge of our field and have been very efficient and fast in supporting the process. I am really looking forward to further collaboration. Thanks. Best regards, Dr. Claudio Ligresti
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I recommend without hesitation submitting relevant papers on medical decision making to the International Journal of Clinical Case Reports and Reviews. I am very grateful to the editorial staff. Maria Emerson was a pleasure to communicate with. The time from submission to publication was an extremely short 3 weeks. The editorial staff submitted the paper to three reviewers. Two of the reviewers commented positively on the value of publishing the paper. The editorial staff quickly recognized the third reviewer’s comments as an unjust attempt to reject the paper. I revised the paper as recommended by the first two reviewers.
Dear Maria Emerson, Editorial Coordinator, Journal of Clinical Research and Reports. Thank you for publishing our case report: "Clinical Case of Effective Fetal Stem Cells Treatment in a Patient with Autism Spectrum Disorder" within the "Journal of Clinical Research and Reports" being submitted by the team of EmCell doctors from Kyiv, Ukraine. We much appreciate a professional and transparent peer-review process from Auctores. All research Doctors are so grateful to your Editorial Office and Auctores Publishing support! I amiably wish our article publication maintained a top quality of your International Scientific Journal. My best wishes for a prosperity of the Journal of Clinical Research and Reports. Hope our scientific relationship and cooperation will remain long lasting. Thank you very much indeed. Kind regards, Dr. Andriy Sinelnyk Cell Therapy Center EmCell
