Effect of Prolonged GnRH Agonist Downregulation on ICSI Outcome in Patients With Endometriomas of Less Than 5 cm: A Randomized Controlled Trial

Gonadotropin-releasing hormone agonist protocols for pituitary suppression in assisted reproduction

BACKGROUND

Gonadotropin-releasing hormone agonists (GnRHa) are commonly used in assisted reproduction technology (ART) cycles to prevent a luteinising hormone (LH) surge during controlled ovarian hyperstimulation (COH) prior to planned oocyte retrieval, thus optimising the chances of live birth. We compared the benefits and risks of the different GnRHa protocols used.

OBJECTIVES

To evaluate the effectiveness and safety of different GnRHa protocols used as adjuncts to COH in women undergoing ART.

SEARCH METHODS

We searched the following databases in December 2022: the Cochrane Gynaecology and Fertility Group's Specialised Register, CENTRAL, MEDLINE, Embase, and registries of ongoing trials. We also searched the reference lists of relevant articles and contacted experts in the field for any additional trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing any two protocols of GnRHa, or variations of the protocol in terms of different doses or duration, used in in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) cycles in subfertile women.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. Our primary outcome measures were number of live births or ongoing pregnancies and incidence of ovarian hyperstimulation syndrome (OHSS) per woman/couple randomised. Our secondary outcome measures included number of clinical pregnancies, pregnancy losses, number of oocytes retrieved, amount of gonadotropins used, and cost and acceptability of the treatment protocols.

MAIN RESULTS

We included 40 RCTs (4148 women). The trials evaluated 10 different comparisons between protocols. The evidence is current to December 2022. Only half of the studies reported the primary outcome of live birth or ongoing pregnancy rates. We restricted the primary analysis of live birth and ongoing pregnancy to trials with low risk of selection and reporting bias. Nineteen studies compared long and short protocols. The primary analysis restricted to trials with low risk of bias included five studies reporting on live birth or ongoing pregnancy rates. Results showed little or no difference when the long protocol was compared with a short protocol (odds ratio (OR) 1.45, 95% confidence interval (CI) 0.83 to 2.52; I² = 0%; 5 studies, 381 women; low-certainty evidence). For the same comparison, there was evidence that the long protocol may improve clinical pregnancy rates when compared to the short protocol (OR 1.56, 95% CI 1.01 to 2.40; I² = 23%; 8 studies, 552 women; low-certainty evidence). No study in this comparison reported on OHSS. We are uncertain if there is a difference between groups in terms of live birth and ongoing pregnancy rates when the following GnRHa protocols were compared: long versus ultrashort (OR 1.78, 95% CI 0.72 to 4.36; 1 study, 150 women; very low-certainty evidence); long luteal versus long follicular phase (OR 1.89, 95% CI 0.87 to 4.10; 1 study, 223 women; very low-certainty evidence); GnRHa reduced-dose versus GnRHa same-dose continued in the long protocol (OR 1.59, 95% CI 0.66 to 3.87; 1 study, 96 women; very low-certainty evidence); GnRHa administration for two versus three weeks before stimulation (OR 0.88, 95% CI 0.37 to 2.05; 1 study, 85 women; very low-certainty evidence); GnRHa continued versus discontinued after human chorionic gonadotropin (HCG) administration in the long protocol (OR 0.89, 95% CI 0.49 to 1.64; 1 study, 181 women; very low-certainty evidence); and 500 µg dose versus 80 µg dose in the short protocol (OR 0.31, 95% CI 0.10 to 0.98; 1 study, 200 women; very low-certainty evidence). Clinical pregnancy rates may improve with a 100 µg dose compared to a 25 µg dose in the short protocol (OR 2.30, 95% CI 1.06 to 5.00; 2 studies, 133 women; low-certainty evidence). Only four of the 40 included studies reported adverse events. We are uncertain of any difference in OHSS rate in the GnRHa reduced-dose versus GnRHa same-dose regimen in the long protocol (OR 0.47, 95% CI 0.04 to 5.35; 1 study, 96 women; very low-certainty evidence) or when administration of GnRHa lasted for two versus three weeks before stimulation (OR 0.93, 95% CI 0.06 to 15.37; 1 study, 85 women; very low-certainty evidence). Regarding miscarriage rates, we are uncertain of any difference when the GnRHa long protocol was administered for two versus three weeks before stimulation (OR 0.93, 95% CI 0.18 to 4.87; 1 study, 85 women; very low-certainty evidence) and when a 500 µg dose was compared with an 80 µg dose in the short protocol (OR 3.15, 95% CI 0.32 to 31.05; 1 study, 131 women; very low-certainty evidence). No studies reported on cost-effectiveness or acceptability of the different treatment protocols. The certainty of the evidence ranged from low to very low. The main limitations were failure to report live birth or ongoing pregnancy rates, poor reporting of methods in the primary studies, imprecise findings due to lack of data, and insufficient data regarding adverse events. Only eight of the 40 included studies were conducted within the last 10 years.

AUTHORS' CONCLUSIONS

When comparing long and short GnRHa protocols, we found little or no difference in live birth and ongoing pregnancy rates, but there was evidence that the long protocol may improve clinical pregnancy rates overall. We were uncertain of any difference in OHSS and miscarriage rates for all comparisons, which were reported by only two studies each. There was insufficient evidence to draw any conclusions regarding other adverse effects or the cost-effectiveness and acceptability of the different treatment protocols.

Impact of treatment interventions of endometriomas prior to in vitro fertilization: a systematic review and meta-analysis

Background

Treatment of endometrioma before in vitro fertilization (IVF) is challenging as it may affect ovarian response to induction.

Objective

A systematic review to search for the available optimal management of ovarian endometrioma before ovulation induction in IVF.

Search strategy

Screening of the MEDLINE, Web of Science, EMBASE, Cochrane database, and the clinical trial registration sites, covering the period from their inception up to June 2023 was done by two reviewers independently using the keywords ovarian endometrioma, ovarian endometriosis, endometrioma/surgery, endometrioma/hormonal treatment, randomized controlled trial(s), case-controlled studies, and cohort studies.

Selection criteria

All types of studies were included. Participants included were women with unilateral or bilateral ovarian endometriomas candidate for IVF/ICSI. We included 18 studies in the review. Three studies were randomized controlled parallel studies, six were prospective cohort, and nine were retrospective cohort studies.

Data collection and analysis

Data from all included studies were extracted by two authors (A. M., A. O.) independently. Data extracted included sample size, population characteristics including age, BMI, duration of infertility, ovarian reserve markers, cyst size, and bilaterality and induction protocol used.

Main results

We found 18 studies. Women with untreated endometrioma had significantly higher numbers of MII oocytes (the mean difference (MD) effect estimate was − 0.53 with [− 1.04, − 0.01] 95% CI and 0.04 P-value), higher number of obtained embryos (MD effect estimate was − 0.25 with [− 0.38, − 0.11] 95%CI and < 0.001 P-value), and required lower doses of gonadotropins for induction (MD effect estimate was 361.14 with [168.13, 5554.15] 95% CI and < 0.001 P-value) compared to those who had undergone surgical management of endometrioma. However, live birth (OR effect estimate was 0.79 with [0.54, 1.18] 95% CI and 0.25 P-value), clinical pregnancy (OR effect estimate was 0.95 with [0.72, 1.26] 95% CI and 0.73 P-value), miscarriage (OR effect estimate was 0.74 with [0.33, 1.63] 95% CI and 0.45 P-value), cancellation rates (OR effect estimate was 1.62 with [0.57, 4.66] 95% CI and 0.37 P-value), and the duration of stimulation (MD effect estimate was 0.19 with [− 0.42, − 0.81] 95% CI and 0.54 P-value) did not show any significant difference between the two groups of women. Hormonal treatment of endometrioma was associated with higher ongoing pregnancy rate (OR effect estimate was 3.39 with [1.83, 6.26] 95% CI and < 0.001 P-value), higher clinical pregnancy rate (OR effect estimate was 3.36 with [2.01, 5.63] 95% CI and < 0.001 P-value), and higher numbers of MII oocytes (MD effect estimate was 2.04 with [0.72, 3.36] 95% CI and 0.003 P-value) when compared to women who did not receive such therapy. These effects were evident in treatment with GnRH agonists, OCPs (oral contraceptive pills), and dienogest, while the miscarriage and cycle cancellation rates did not show these differences.

Conclusions

The optimal approach for treating endometrioma prior to IVF is not clear yet due to lack of well-designed randomized controlled trials.

Registration number

CRD42020151736.

Factors affecting cumulative live birth rate after the 1st oocyte retrieved in polycystic ovary syndrome patients in women during IVF/ICSI-ET

BACKGROUND

The factors affecting the cumulative live birth rate (CLBR) of PCOS (Polycystic ovary syndrom) patients who received in vitro fertilization/intracytoplasmic sperm injection-embryo transfer (IVF/ICSI-ET) needs more research for a better outcome.

METHODS

Here we carried out a retrospective analysis of 1380 PCOS patients who received IVF/ICSI-ET for the first time from January 2014 to December 2016. We divided them into cumulative live birth group (group A) and non-cumulative live birth group (group B) according to whether there were live births.

RESULTS

The conservative cumulative live birth rate was 63.48%. There were 876 cumulative live births (group A) and 504 non-cumulative live births (group B) according to whether the patients had live births or not. Competition analysis showed that duration of infertility, primary/secondary type of infertility, stimulation protocols, starting dose of gonadotrophins and oocyte retrieved numbers were significantly correlated with CLBR. The Cox proportional risk regression model of PCOS patients showed that stimulation protocols had a significant impact on CLBR. Patients in the GnRH (Gonadotropin-releasing hormone)-antagonist protocol group and the mild stimulation protocol had lower CLBR than those in the prolonged GnRH-agonist protocol, which was statistically significant. PCOS patients with the starting dose of gonadotrophins greater than 112.5u had lower CLBR than those with less than 100u, which was statistically significant. Women with 11-15 oocytes and 16-20 oocytes had higher CLBR than women with 1-9 oocytes, which was statistically significant.

CONCLUSIONS

When we used Prolonged GnRH-agonist protocol, or the first starting dose of gonadotrophins was 100u-112.5u, or the number of oocytes obtained was 11-15 and 16-20, the CLBR of PCOS patients increased significantly after the 1st oocyte collection.

Exploring the Impact of Endometrioma Aspiration and Dienogest Combination Therapy on Cyst Size, Inflammatory Cytokines in Follicular Fluid and Fertility Outcomes

Endometriomas (chocolate cysts) are cystic lesions that can develop on ovaries, and are characterized by the presence of ectopic endometrial tissue or similar tissue. Such lesions can cause a decline in the number and quality of oocytes, and lead to implantation failure. In this study, we retrospectively assessed the efficacy of repeated endometrioma aspiration and dienogest combination therapy in patients suffering endometriosis-associated infertility with endometriomas. A comparison was made between a treated group that underwent combination therapy followed by controlled ovarian hyperstimulation (COH) (n = 30) and a control group that did not undergo treatment (n = 40), at the IVF Osaka Clinic from September 2019 to September 2021. There were no differences in patient background between the two groups. A reduction in endometrioma size continued for 12 months after treatment. The numbers of follicles that developed to 15 mm or greater in size following COH and mature oocytes were significantly lower in the treated group compared to those in the control group. The levels of inflammatory cytokines in the follicular fluid significantly decreased in the treated group (p < 0.05). In patients in the treated group who underwent a second ova retrieval, the results were compared between those in the first ova retrieval (immediately after the end of treatment) and those in the second ova retrieval (four months after the first retrieval). The numbers of follicles following COH, retrieved, mature and fertilized ova were significantly increased in the second ova retrieval.

Comparison of two gonadotropin-releasing hormone agonist suppression protocols for in vitro fertilization in young patients with low body mass index

OBJECTIVE

To evaluate two different gonadotropin-releasing (pituitary downregulating) hormones used in in vitro fertilization (IVF) on the live birth rate in young patients with low body mass index (BMI) undergoing their first IVF cycle.

METHODS

In a retrospective study in a single public medical center, 555 long gonadotropin-releasing hormone agonist (GnRH-a) protocols were compared with 431 prolonged GnRH-a protocols between 2016 and 2018. All analyses were performed using the SPSS version 22.0. The primary measured outcome was live birth rate.

RESULTS

Compared with the long protocol, the prolonged protocol required more doses of gonadotropin and a longer duration of ovarian stimulation. Lower levels of serum luteinizing hormone and serum estrogen were detected on the day of chorionic gonadotropin administration, and a lower fertilization rate was found in the prolonged protocol. Although more oocytes were retrieved and more frozen embryos were recorded in the prolonged protocol, the live birth rate per fresh cycle was comparable between the two protocols (P = 0.057). The incidence of ovarian hyperstimulation syndrome was higher in the prolonged protocol group. In the subgroup of women with antral follicle count (AFC) of 12 or less, there was no difference in the live birth rate between the two protocols (P = 0.688). However, for women with AFC > greater than 12, the prolonged protocol was still a positive predictor of live birth rate. The odds ratio was 1.73 (95% confidence interval 1.04-2.89).

CONCLUSION

The prolonged protocol might not increase the live birth rate in women with low BMI who are undergoing their first IVF cycle. However, for women with AFC greater than 12, a prolonged protocol could be a good choice to improve the live birth rate.

Effectiveness of ultra-long protocol on in vitro fertilization/intracytoplasmic sperm injection-embryo transfer outcome in infertile women with endometriosis: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate the effectiveness of ultra-long protocol on reproductive and controlled ovarian hyperstimulation outcome in in vitro fertilization/intracytoplasmic sperm injection-embryo transfer (IVF/ICSI-ET) in infertile women with endometriosis versus long protocol.

METHODS

We retrieved articles without language restrictions in the Elsevier ScienceDirect, Embase, Medline, PubMed, Web of Science, China National Knowledge Infrastructure, Wan Fang Data Knowledge Service Platform and China Science and Technology Journal Database from inception to August 2020. RCTs including the comparison of reproductive outcome of infertile patients with endometriosis who underwent ultra-long protocol and long protocol were selected. Data extraction was conducted using RevMan 5.3.

RESULTS

A total of nine RCTs in compliance with the standard literature were included. This meta-analysis suggested that ultra-long protocol with a 3-month downregulation could increase clinical pregnancy rate of infertile women with endometriosis (RR=1.31, 95% CI:1.11 ~ 1.55, P = 0.002) versus long protocol. However, subgroup analysis found the different protocol provided no significant difference in improving clinical outcomes in patients with different disease stage of endometriosis.

CONCLUSION

The ultra-long protocol could improve the clinical pregnancy rate of infertile women with endometriosis compared with long protocol with a 3-month downregulation. And ultra-long protocol could be effective to increase the ongoing pregnancy rate compared to long-protocol. But, the efficacy of ultra-long protocol is not different between early and advanced stage of endometriosis.

Prediction of metaphase II oocytes according to different levels of serum AMH in poor responders using the antagonist protocol during ICSI: a cohort study

The aim of our study was to assess the value of serum AMH in prediction of metaphase II oocytes in poor responders. We performed a prospective cohort study included 206 poor responders candidate for ICSI using antagonist protocol. They were classified into 3 groups. Group I included 50 women with AMH < 0.3 ng/ml, group II included 85 women with AMH 0.3-0.7 ng/ml and group III included 71 women with AMH > 0.7-1.0 ng/ml. The primary outcome parameter was the number of MII oocytes. There was a highly significant difference between the study groups regarding E2 at triggering (481.41 ± 222.653, 648.17 ± 264.353 and 728.74 ± 305.412 respectively, number of oocyte retrieved (2.37 ± 1.178, 3.38 ± 1.622 and 3.80 ± 1.427 respectively), number of MII oocytes (1.66 ± 1.039, 2.35 ± 1.171 and 2.61 ± 1.080 respectively), number of fertilized oocytes (1.39 ± 0.919, 1.91 ± 0.983 and 2.21 ± 0.937 respectively), , total number of embryos (1.34 ± 0.938, 1.76 ± 0.956 and 2.09 ± 0.907 respectively), clinical pregnancy rates (4.9 vs. 7.7 and 19.7% respectively). We concluded that AMH is a good predictor for number of MII oocytes in poor responders undergoing ICSI.

The effectiveness of different down-regulating protocols on in vitro fertilization-embryo transfer in endometriosis: a meta-analysis

BACKGROUND

To investigate the effectiveness of the GnRH-a ultra-long protocol, GnRH-a long protocol, and GnRH-a short protocol used in in vitro fertilization-embryo transfer (IVF-ET) in infertile women with endometriosis.

METHODS

We searched PubMed, Embase, Web of Science, Cochrane Library, Elsevier Science Direct, OA Library, Google Scholar, China National Knowledge Infrastructure (CNKI), Wanfang Data Knowledge Service Platform, China Science and Technology Journal database, and the China Biology Medicine disc for randomized controlled trials (RCTs) and observational studies (non-RCTs) to evaluate the efficacy of the GnRH-a ultra-long protocol, GnRH-a long protocol, and GnRH-a short protocol in IVF-ET in infertile patients with endometriosis.

RESULTS

A total of 21 studies in compliance with the standard literature were included, and RCT and non-RCT studies were analyzed separately. This meta-analysis showed that the GnRH-a ultra-long protocol could improve the clinical pregnancy rate of infertile patients in RCT studies, especially in patients with stages III-IV endometriosis (RR = 2.04, 95% CI: 1.37~3.04, P < 0.05). However, subgroup analysis found the different down-regulation protocols provided no significant difference in improving clinical outcomes in patients with endometriosis in the non-RCT studies.

CONCLUSION

This study suggests that the GnRH-a ultra-long protocol can improve the clinical pregnancy rate of the patients with stages III-IV endometriosis in RCT studies. Although it is generally believed that the results of RCT are more reliable, the conclusions of the non-RCT studies cannot be easily neglect, which let us draw conclusions more cautious.

Long-term GnRH agonist therapy before in vitro fertilisation (IVF) for improving fertility outcomes in women with endometriosis

BACKGROUND

Endometriosis is known to have an impact on fertility and it is common for women affected by endometriosis to require fertility treatments, including in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI), to improve the chance of pregnancy. It has been postulated that long-term gonadotrophin-releasing hormone (GnRH) agonist therapy prior to IVF or ICSI can improve pregnancy outcomes. This systematic review supersedes the previous Cochrane Review on this topic (Sallam 2006).

OBJECTIVES

To determine the effectiveness and safety of long-term gonadotrophin-releasing hormone (GnRH) agonist therapy (minimum 3 months) versus no pretreatment or other pretreatment modalities, such as long-term continuous combined oral contraception (COC) or surgical therapy of endometrioma, before standard in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) in women with endometriosis.

SEARCH METHODS

We searched the following electronic databases from their inception to 8 January 2019: Cochrane Gynaecology and Fertility Specialised Register of Controlled Trials, CENTRAL via the Cochrane CENTRAL Register of Studies ONLINE (CRSO), MEDLINE, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL). We searched trial registries to identify unpublished and ongoing trials. We also searched DARE (Database of Abstracts of Reviews of Effects), Web of Knowledge, OpenGrey, Latin American and Caribbean Health Science Information Database (LILACS), PubMed, Google and reference lists from relevant papers for any other relevant trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) involving women with surgically diagnosed endometriosis that compared use of any type of GnRH agonist for at least three months before an IVF/ICSI protocol to no pretreatment or other pretreatment modalities, specifically use of long-term continuous COC (minimum of 6 weeks) or surgical excision of endometrioma within six months prior to standard IVF/ICSI. The primary outcomes were live birth rate and complication rate per woman randomised.

DATA COLLECTION AND ANALYSIS

Two independent review authors assessed studies against the inclusion criteria, extracted data and assessed risk of bias. A third review author was consulted, if required. We contacted the study authors, as required. We analysed dichotomous outcomes using Mantel-Haenszel risk ratios (RRs), 95% confidence intervals (CIs) and a fixed-effect model. For small numbers of events, we used a Peto odds ratio (OR) with 95% CI instead. We analysed continuous outcomes using the mean difference (MD) between groups and presented with 95% CIs. We studied heterogeneity of the studies via the I2 statistic. We assessed the quality of evidence using GRADE criteria.

MAIN RESULTS

We included eight parallel-design RCTs, involving a total of 640 participants. We did not assess any of the studies as being at low risk of bias across all domains, with the main limitation being lack of blinding. Using GRADE methodology, the quality of the evidence ranged from very low to low quality. Long-term GnRH agonist therapy versus no pretreatment We are uncertain whether long-term GnRH agonist therapy affects the live birth rate (RR 0.48, 95% CI 0.26 to 0.87; 1 RCT, n = 147; I2 not calculable; very low-quality evidence) or the overall complication rate (Peto OR 1.23, 95% CI 0.37; to 4.14; 3 RCTs, n = 318; I2 = 73%; very low-quality evidence) compared to standard IVF/ICSI. Further, we are uncertain whether this intervention affects the clinical pregnancy rate (RR 1.13, 95% CI 0.91 to 1.41; 6 RCTs, n = 552, I2 = 66%; very low-quality evidence), multiple pregnancy rate (Peto OR 0.14, 95% CI 0.03 to 0.56; 2 RCTs, n = 208, I2 = 0%; very low-quality evidence), miscarriage rate (Peto OR 0.45, 95% CI 0.10 to 2.00; 2 RCTs, n = 208; I2 = 0%; very low-quality evidence), mean number of oocytes (MD 0.72, 95% CI 0.06 to 1.38; 4 RCTs, n = 385; I2 = 81%; very low-quality evidence) or mean number of embryos (MD -0.76, 95% CI -1.33 to -0.19; 2 RCTs, n = 267; I2 = 0%; very low-quality evidence). Long-term GnRH agonist therapy versus long-term continuous COC No studies reported on this comparison. Long-term GnRH agonist therapy versus surgical therapy of endometrioma No studies reported on this comparison.

AUTHORS' CONCLUSIONS

This review raises important questions regarding the merit of long-term GnRH agonist therapy compared to no pretreatment prior to standard IVF/ICSI in women with endometriosis. Contrary to previous findings, we are uncertain as to whether long-term GnRH agonist therapy impacts on the live birth rate or indeed the complication rate compared to standard IVF/ICSI. Further, we are uncertain whether this intervention impacts on the clinical pregnancy rate, multiple pregnancy rate, miscarriage rate, mean number of oocytes and mean number of embryos. In light of the paucity and very low quality of existing data, particularly for the primary outcomes examined, further high-quality trials are required to definitively determine the impact of long-term GnRH agonist therapy on IVF/ICSI outcomes, not only compared to no pretreatment, but also compared to other proposed alternatives to endometriosis management.