An observational study of assisted reproductive technology outcomes in new European Union member states: an overview of protocols used for ovarian stimulation

BACKGROUND

The development of new fertility treatment options has facilitated individualized assisted reproductive technology (ART) protocols to improve outcomes. Manufacturing improvements to recombinant human follitropin alfa have allowed precise dosing based on mass (filled-by-mass; FbM) rather than bioactivity (filled-by-bioassay; FbIU). Continued monitoring and reporting of follitropin alfa treatment outcomes in routine clinical practice is essential.

OBJECTIVE

To provide an overview of the frequency of different controlled ovarian-stimulation protocols used in in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) cycles in new European Union member states, and to provide post-registration efficacy and safety data on follitropin alfa.

RESEARCH DESIGN AND METHODS

A 2-year, prospective, observational, multicentre, Phase IV study conducted at ART clinics in the Czech Republic, Estonia, Latvia, Lithuania, Poland, Slovakia and Slovenia. Women aged 18-47 years undergoing ovarian stimulation with follitropin alfa for conventional IVF or ICSI were eligible for inclusion. The main treatment outcome was cumulative clinical pregnancy rate. Data were analysed descriptively.

RESULTS

Clinical pregnancy outcomes were available for 4055 of 4085 (99.3%) patients. In total, 1897 (46.8%) patients used follitropin alfa FbIU; 2133 (52.6%) used follitropin alfa FbM. Clinical pregnancy was achieved by 39.5% (1603/4055) of patients. A greater proportion of patients with polycystic ovary syndrome achieved a clinical pregnancy than those with endometriosis (41.8% vs 37.8%, respectively). A higher cumulative pregnancy rate was observed with the use of follitropin alfa FbM than follitropin alfa FbIU (41.3% vs 37.8%, respectively; p = 0.02).

CONCLUSIONS

This study represents the most comprehensive audit of individualized ART in clinical practice in Central and Eastern Europe. Overall, clinical pregnancy was achieved by 39.5% of patients after stimulation with follitropin alfa. The use of follitropin alfa FbM resulted in a higher cumulative pregnancy rate than did the FbIU formulation. However, limitations of the study include the observational and non-comparative study design, and descriptive nature of statistical analyses; furthermore, the study was not designed to make direct comparisons between the success rates of different ovarian-stimulation protocols.

Combined analysis of endometrial thickness and pattern in predicting outcome of in vitro fertilization and embryo transfer: a retrospective cohort study

OBJECTIVE

To evaluate the combined effect of endometrial thickness and pattern on clinical outcome in patients undergoing in vitro fertilization/intracytoplasmic sperm injection and embryo transfer (IVF/ICSI-ET).

METHODS

Cycles of IVF/ICSI-ET conducted between January 2003 and December 2008 at a university-based reproductive center were reviewed retrospectively. Endometrial ultrasonographic characteristics were recorded on the day of hCG administration. In the combined analysis, endometrial thickness groups (group 1: equal or <7 mm; group 2: 7-14 mm; group 3: >14 mm) were subdivided into two endometrial patterns (pattern A: triple-line; pattern B: no-triple line). Clinical pregnancy rate (CPR) and early miscarriage rate in different groups were analyzed.

RESULTS

A total of 2896 cycles were reviewed. Clinical pregnancy rate (CPR) was 24.4% in group 1-A. There were no second trimester pregnancies in group 1-B. Miscarriage rate in group 2-A was significantly lower compared to group 2-B (P < 0.01), although CPR did not show any significant differences between the groups. A no-triple line endometrial pattern with moderate endometrial thickness (7-14 mm) had a detrimental effect on pregnancy outcome, but not the occurrence of pregnancy. In group 3, there was no difference in CPR and miscarriage rates between the two patterns; adequate endometrial thickness (>14 mm) seemed to mitigate the detrimental impact (high miscarriage rate) of pattern B.

CONCLUSION

Combined analysis of endometrial thickness and pattern on the day of hCG administration was a better predictor of the outcome of IVF/ICSI-ET and may be more helpful for patient counseling than the separate analyses.

Discontinuation of rLH two days before hCG may increase the number of oocytes retrieved in IVF

BACKGROUND

Administration of recombinant luteinizing hormone (rLH) in controlled ovarian hyperstimulation may benefit a subpopulation of patients. However, late follicular phase administration of high doses of rLH may also reduce the size of the follicular cohort and promote monofollicular development.

METHODS

To determine if rLH in late follicular development had a negative impact on follicular growth and oocyte yield, IVF patients in our practice who received rFSH and rLH for the entire stimulation were retrospectively compared with those that had the rLH discontinued at least two days prior to hCG trigger.

RESULTS

The two groups had similar baseline characteristics before stimulation with respect to age, FSH level and antral follicle count. However, the group which had the rLH discontinued at least two days prior to their hCG shot, had a significantly higher number of oocytes retrieved, including a higher number of MII oocytes and number of 2PN embryos.

CONCLUSIONS

When using rLH for controlled ovarian hyperstimulation, administering it from the start of stimulation and stopping it in the late follicular phase, at least two days prior to hCG trigger, may increase oocyte and embryo yield.

Effects of prolonging administration gonadotropin on unexpectedly poor ovarian responders undergoing in vitro fertilization

BACKGROUND

There are still some patients who show poor response to ovarian stimulation prior to evidence of normal ovarian reserve in vitro fertilization. However, there are few studies about how to treat the unexpectedly ovarian poor responder in vitro fertilization. The main aim of this study evaluate the effect of prolonging administration follicle-stimulating hormone in woman with the unexpectedly ovarian poor responder in vitro fertilization on implantation rate, clinical pregnancy rate and live birth rate.

METHODS

922 patients subjected to IVF were divided into two groups according to the predicted criterion of ovarian poor response. 116 patients predicted poor response received the short protocol (group C). The others received the long protocol, among the latter, there were 149 patients undergoing unexpectedly ovarian poor response (group B) and 657 patients exhibited normal ovarian response (group A). The doses of gonadotropin, duration of administration, implantation rate, clinical pregnancy rate and live birth rate were recorded among three groups.

RESULTS

The implantation rate of embryo, clinic pregnancy rate and delivery rate are similar between the group A and group B, while there are significant differences between the doses of gonadotropins (35.1 +/- 8.9 ampules vs.53.0 +/- 15.9 ampules) and the duration of administration (15.3 +/- 3.6D vs. 9.8 +/- 2.6D) of these two groups. There are no significant differences about clinical pregnancy rate and live birth rate between group B and group C.

CONCLUSION

Prolonging administration gonadotropin on the unexpectedly poor ovarian responders does not lower live birth rate in vitro fertilization.

Effect of dietary crude protein source on hormone and follicle characteristics in beef heifers

Ground, raw soybeans (SB), or dried distillers grain plus solubles (DDGS) were utilized in heifer development diets to determine the effect of dietary fat and protein source on hormone and follicle characteristics and ADG. The experiment was conducted over 2 yr with 100 June-born heifers (199 +/- 2 kg initial BW, n = 50 per yr). The experimental periods were 157 and 207 d in yr 1 and 2, respectively. Heifers were provided a dietary supplement (DM basis) of 1.23 kg of SB and 0.40 kg of corn or 1.65 kg of DDGS between weaning and breeding. Estrus was synchronized with 2 injections of PGF(2alpha) 14 d apart. Dominant follicles were measured and aspirated via transvaginal ultrasonography 60 h after the second PGF(2alpha) injection. Heifers were exposed to bulls beginning 14 d after aspiration for 45 d. Heifer ADG was greater (P = 0.02) for DDGS heifers in yr 1, but was similar (P = 0.47) in yr 2. However, there was no difference (P = 0.35) in final BW in either year. There was no difference (P >or= 0.67) in follicle size, follicle hormone concentrations, or pregnancy rate (88%) between yr 1 and 2. Serum estrogen at 48 or 60 h after PGF(2alpha) injection were similar (P >or= 0.91); however, LH at 60 h in yr 2 tended to be greater (P = 0.07) for DDGS heifers. The percentage of heifers experiencing an LH surge 48 and 60 h after PGF(2alpha) injection was not affected (P >/= 0.40) by treatment. Calf production was not affected (P >or= 0.20) by developmental diet. In summary, DDGS and SB have similar effects on hormone and follicle characteristics at the inclusion rates used in these studies.

[Clinicals and biological aspects of ICSI cycles on patients with polycystic ovary syndrome]

AIM

To analyse clinical et biological pecularities of Polycystics Ovarian Syndrome (PCOS) patients enrolled on ICSI cycles and compare them to normo-ovulatory women.

METHODS

100 controlled ovarian stimulation cycles for ICSI in women with PCOS and 200 cycles in normo-ovulatory women.

RESULTS

There was no significant difference in term of cancellation rate (5.5% in PCOS group vs 5%; NS). The mean number of follicles was higher in patients with PCOS (18.1 +/- 8.5 vs 9.4 +/- 5.5; p < 0.05). Oocyte mature rate and fertilization rate were higher in PCOS group (67% vs 52%; p < 0.05) (75% vs 63.7%; p < 0.05) respectively. Grade 1 embryo rate was significantly higher in PCOS group (69% vs 53%; p < 0.05). Implantation rate (16.6% vs 12.1%; NS) and clinical pregnancy rate per transfer (31.5% vs 22.2%; NS) did not differ statistically in the two groups. Miscarriage rate was higher in PCOS group but this did not reach the statistical significance (20% vs 7.1%; NS). 11 cases of Ovarian hyperstimulation syndrome occurred in PCOS group versus 4 on normo-ovulatory group.

CONCLUSION

Use of ICSI as fertilization technique was correlated with good biologic parameters on PCOS patients with better fertilization rate and embryo quality and similar pregnancy rate comparing to normo-ovulatory women. However, it still be great concern about high risk of miscarriages and Hyperstimulation ovarian syndrome.

Clomiphene citrate vs. letrozole for cryopreserved-thawed embryo transfer: a randomized, controlled trial

OBJECTIVE

To assess the endometrial thickness, hormonal status and pregnancy rates with clomiphene citrate (CC) vs. letrozole in frozen-thawed embryo transfer protocols.

STUDY DESIGN

Nineteen patients who had previously undergone in vitro fertilization (IVF) with embryo cryopreservation were prospectively and randomly enrolled in a randomized, controlled trial. Nine patients were treated with CC, 100 mg per day, from day 3 to day 7 of the cycle, and 10 patients were treated with letrozole, 2.5 mg per day, on the same cycle days. beta-Human chorionic gonadotropin (beta-hCG) was administrated when the leading follicular size was > or = 18 mm. Endometrial thickness was measured on cycle day 8, beta-hCG day, transfer day and 7 days after embryo transfer. Estradiol levels were determined on the day of beta-hCG administration.

RESULTS

Patients' ages and number of previous unsuccessful IVF cycles were similar between the 2 groups. Endometrial thickness was significantly higher in the letrozole group as compared to the CC group on the day of beta-hCG administration (9.1 +/- 3.6 vs. 6.9 +/- 1.2 mm, p<0.05), on the day of embryo transfer (10 +/- 1.7 vs. 7.6 +/- 1.4 mm, p<0.05) and 7 days after embryo transfer (12.2 +/- 0.4 vs. 9.0 +/- 3.0 mm, p<0.05). Estradiol levels in the letrozole group were significantly lower than in the CC group on the beta-hCG day (231 +/- 132 vs. 515 +/- 363 pg/L, p<0.05). Pregnancy was not achieved in either group.

CONCLUSION

Endometrial thickness is improved by letrozole as compared to CC in frozen-thawed embryo transfer cycles. Further investigation is needed to assess pregnancy and implantation rates.

[Semen cryopreservation applied to intrauterine insemination cycles for oligospermia and asthenospermia in infertile men]

OBJECTIVE

To explore the application value of semen cryopreservation in intrauterine insemination cycles for the treatment of oligospermia and asthenospermia in infertile males.

METHODS

A total of 152 cycles of intrauterine insemination were performed for 103 couples with constitutional infertility, which were divided into Groups 1 (normal semen, n=53), 2 (oligospermia and asthenospermia, n=52) and 3 (fresh combined with cryopreserved semen, n=47). Semen parameters and forward motile sperm count after processing were recorded by Makler chamber, and all were followed up for the outcome of clinical pregnancy.

RESULTS

Compared with Group 2, Group 3 showed obviously lower semen volume, sperm motility and grade a sperm count before semen processing, with extremely significant differences (P < 0.01), but a higher rate of grade a sperm after semen processing, though with no significant differences (P > 0.05). There were no statistically significant differences in the pregnancy rate between Groups 2 and 3 (9.6% versus 14.9%, P > 0.05).

CONCLUSION

Semen cryopreservation can improve the forward motile sperm count and pregnancy rate in oligospermia and asthenospermia patients after intrauterine insemination. Semen cryopreservation combined with intrauterine insemination seems an ideal treatment for oligospermia and asthenospermia in infertile men.

Microtubal reanastomosis: success rates as compared to in vitro fertilization

OBJECTIVE

To determine the pregnancy rates of microtubal reanastomosis (MTR) and any associated clinical variables, to determine pregnancy rates and live birth rates of MTR as compared to in vitro fertilization (IVF) and to study the rates of ectopic pregnancy and spontaneous abortion (SAB) after MTR.

STUDY DESIGN

Retrospective chart review.

RESULTS

At our institution, the pregnancy rate in the first 12 months following MTR was 44.3%. The study also showed that 2 clinical variables of the MTR procedure that had higher pregnancy rates were when Hulka clips (Hulka-Clemens, Richard Wolf, Rosemont, Illinois) or Filshie clips (Coopersurgical, Lake Forest, California) were used as the mechanism of tubal occlusion and if bilateral MTR was performed instead of unilateral. There was not a significant difference in the pregnancy rates of MTR (44.3%) vs. IVF (38%). However, there was a statistically significant difference in the live birth rate of MTR (19%) vs. IVF (31%) (p=0.007). The rates of ectopic pregnancy and SAB after MTR were 10% and 15.7%, respectively.

CONCLUSION

This study showed a significantly higher live birth rate when patients underwent IVF as compared to MTR in the first 12 months following an MTR procedure.

Assisted reproductive technologies in public and private clinics

The aim of this study was to analyse the influence of the type of service provided by assisted reproduction clinics. The activities, treatment patterns and results achieved by assisted reproduction centres in Spain were examined, comparing public and private clinics. A retrospective study was carried out using the Assisted Reproductive Technology Register of the Spanish Fertility Society for 2002-2004. The results showed that 74%, 96% and 99% of IVF/intracytoplasmic sperm injection, oocyte donation and preimplantation genetic diagnosis cycles, respectively, were carried out in the private sector. Public clinics performed proportionally more transfers of three embryos than the private clinics (48.1% versus 41.7%). More elective transfers were performed in private clinics. Pregnancy rates per cycle started, per puncture and per transfer were significantly higher among private than public clinics (29.1%, 32.7% and 35.9% versus 25.2%, 28.5% and 32.6%, respectively) (P < 0.05). Implantation rate has risen year on year in both types of clinic and was significantly higher (P < 0.05), every year, among the private clinics. The multiple-pregnancy rate was significantly higher among the private clinics (30.8% versus 26.4%) (P < 0.05). In conclusion, differences exist between public and private clinics as regards to their volume of activity, the range of services offered, clinical practice and results achieved.

Improved pregnancy rate with administration of hCG after intrauterine insemination: a pilot study

BACKGROUND

In natural cycles, women conceive when intercourse takes place during a six-day period ending on the day of ovulation. The current practice in intrauterine insemination (IUI) cycles is to perform the IUI 24-36 hours after the hCG administration, when the ovulation is already imminent. In this study hCG was administered after the IUI, which more closely resembles the fertilisation process in natural cycles.

METHODS

All the IUIs performed since the beginning of 2007 were analysed retrospectively. Our standard protocol has been to perform the IUI 24-32 hours after hCG administration. From the end of 2008, we started to inject hCG after the IUI at random. The main outcome measure was the result of a urinary pregnancy test. Generalized Estimating Equations (GEE) was used to identify independent factors affecting the cycle outcome.

RESULTS

The analysis included 228 cycles with hCG administered before and 104 cycles hCG administered after the IUI. The pregnancy rates were 10.9% and 19.6% (P = 0.040), respectively. Independent factors (OR, 95% CI) affecting the cycle outcome were sperm count (2.65, 1.20-5.81), number of follicles > 16 mm at IUI (2.01, 1.07-3.81) and the time of hCG administration (2.21, 1.16-4.19).

CONCLUSION

Improved pregnancy rate was observed with administration of hCG after IUI.

[Effect of oral contraceptive pills upon IVF outcomes of patients under a short GnRH agonist protocol]

OBJECTIVE

To determine the link between oral contraceptive pill (OCP) use and IVF/ICSI treatment outcomes under a short GnRH agonist protocol.

METHODS

A total of 186 patients (one cycle each patient) received a short GnRH agonist protocol at Day 2 of menstrual cycle for IVF/ICSI. Among them, 83 patients took OCP pre-treatment prior to the stimulation protocol (OCP group) and 103 patients received no OCP (non-OCP group). The triggering of final oocyte maturation was performed with 10 000 IU of hCG.

RESULTS

The ongoing pregnancy rates per started cycle in the non-OCP group and OCP group were 27.8% and 12.7% (P < 0.05) respectively. The clinical pregnancy rate and embryo implantation rate were significantly reduced in OCP group (clinical pregnancy rate 16.5%, implantation rate 11.2%) as compared with non-OCP group (32.2% and 19.9%, P < 0.05). The endometrium on hCG day was thicker in non-OCP group than OCP group (9.5 mm vs 8.7 mm, P < 0.05).

CONCLUSION

Pretreatment with OCP, as compared with initiation of stimulation at Day 2 of cycle in patients treated with GnRH-a short protocol antagonist appears to be associated with a significant difference in ongoing pregnancy rates per started cycle.

Embryo loss in cattle between Days 7 and 16 of pregnancy

Embryo loss between embryonic Days 7 and 16 (Day 0=day of IVF) in nonlactating cattle, Bos taurus, was analyzed using transfer of 2449 (in groups of 3 to 30) in vitro-produced (IVP) blastocysts. In 152 transfers, pregnancy losses attributable solely to recipient failings amounted to between 6% (beef heifers) and 16% (parous dairy cows), of which 3% were caused by uterine infections. Neither season, year, nor the age of the embryos on retrieval affected pregnancy rates. The latter observation indicated that the reason that a recipient failed to retain embryos was already present at the time of transfer. Notably, the proportion of embryos recovered decreased (P=0.03) as more embryos were transferred, particularly at later stages (Day 14, P<0.01). The average length of embryos decreased by approximately 5% for every additional embryo transferred (P<0.0001). These effects may be linked to embryonic migration. Embryo mortality inherent to the embryo during the second week of pregnancy was 24%. Additionally, 9% of Day 14 embryos were of inferior quality, as they did not contain an epiblast. Combining embryo and recipient causes but excluding infection effects, embryonic loss of IVP embryos during the second week of pregnancy amounted to 26% (heifers) or 34% (parous dairy cows). The length of embryos doubled every day between Days 9 and 16, with a 4.4-fold range in sizes representing two thirds of the variation in length. Embryos retrieved from heifers were twice the size of those incubated in parous cows (P<0.0001), indicating faster embryonic development/trophoblast proliferation in heifers. Whereas season did not affect embryo recoveries, length was lower (50%) in winter (winter-autumn, P<0.05; winter-spring, P<0.001). Lastly, transuterine migration in cattle, when transferring multiple embryos, commenced at Day 14 (4%) and had occurred in all recipients by Day 16 (38% of embryos found contralaterally).

[Analysis of the clinical outcomes of 160 patients undergoing repeated IVF/ICSI-ET treatment]

OBJECTIVE

To study the clinical factors affecting the outcomes of repeated assisted reproductive technology (ART) cycles.

METHODS

A retrospective analysis of the clinical data and outcomes was conducted among 160 patients undergoing repeated IVF/ICSI-ET treatment between January 2006 and April 2009.

RESULTS

The patients with successful clinical pregnancy after two ART cycles (group A) had a younger age and shorter duration of infertility, and had more antral follicles (AFC), more eggs and good-quality embryos with more transferred embryos available and higher good-quality embryo rate (P<0.05) than those who failed to have pregnancy after the cycles (group B). In the second cycle, the patients in group A had higher doses of short-acting GnRHa, r-HCG and HMG and at the same time more good eggs and embryos than in the first cycle.

CONCLUSIONS

Female age is one of the most important factors affecting the pregnancy rate after repeated ART cycles. The clinical pregnancy rate can be enhanced by administering short-acting GnRHa, HMG, oral contraceptives and adjusting the dose of Gn as well as changing the culture medium of embryos.

[Early rescue intracytoplasmic sperm injection: safe for complete IVF failure]

OBJECTIVE

To evaluate the safety of early rescue intracytoplasmic sperm injection (ICSI) for complete failure of in vitro fertilization (IVF).

METHODS

We conducted early rescue ICSI for 105 conventional IVF cycles and follow-up evaluation of the clinical outcomes.

RESULTS

A total of 64 neonates were born, and no significant differences were found in the sex ratio, birth weight and birth defects.

CONCLUSION

Early rescue ICSI can significantly improve the clinical outcome in patients with complete IVF failure, but does not increase the clinical risk.

[Predictive factors of success in ovulation induction with recombinant FSH: results of Indigo study]

INTRODUCTION

Although ovulation induction is commonly used to treat infertility, few data are available concerning this treatment. Therefore, the aim of this prospective observational study was to describe medical practices and to identify predictive outcome factors of ovarian stimulation by recombinant FSH (r-hFSH), administrated with a self-injector pen.

PATIENTS AND METHODS

At the time of the prescription of ovarian stimulation followed by sexual intercourse (SI) or artificial insemination (HAI) with a normal husband sperm, 370 gynaecologists consecutively sent from January to November 2005, for a maximum of six patients (1398 patients in total), a form dealing with the assessment of infertility factors prior to stimulation (n=1340), then a monitoring form of the treated cycle (n=1227) and when a pregnancy was obtained, a follow-up form at 12 weeks of amenorrhea (n=254). Each patient had to complete an autoquestionnaire about the use of the pen (n=1044).

RESULTS

Seventy percent of the contributing gynaecologists had only a private practice. The mean age of patients was 31.9+/-4.8 years. Dealing with infertility exploration prior to stimulation, 9% did not have tubal assessment. Although it was the first stimulation attempt for 52% of cases, 91% of patients found the pen easy to manipulate. The mean duration of r-hFSH administration was 8.8+/-3.7 days and the mean daily dose was 75.4+/-29.4 IU. Ultrasound and hormonal monitoring was performed for 88% of patients. The cycle cancellation rate was 11%. The hCG administration was performed on cycle day 13+/-3. An HAI was programmed in 60% of patients and SI in 40%. The pregnancy rates for positive betahCG, ongoing and multiple pregnancies were, respectively, 22.7, 18 and 16% (twins 14%; 2% of triplets or more 2%). Three prognosis factors were independently related to ongoing pregnancy rate: age<35 years, previous pregnancy obtained by treatment and presence of ovulatory disorders.

DISCUSSION AND CONCLUSION

This observatory of ovarian stimulation out of FIV allowed to describe medical practices of gynaecologists: infertility assessment prior to ovarian stimulation, used FSH doses, ultrasound and hormonal monitoring, and it outlined three predictive factors of outcome: age, previous pregnancy obtained by treatment and presence of ovulatory disorders.

[Correlation between serum progesterone level at the day with human chorionic gonadotrophin administration and the outcome of pregnancy in in-vitro fertilization]

OBJECTIVE

To investigate the relationship between serum progesterone level at the day with human chorionic gonadotrophin (hCG) administration and pregnant outcome from in in-vitro fertilization-embryo transfer (IVF-ET).

METHODS

From Mar. 2002 to Apr. 2007, 786 cycles with serum progesterone measurement on the day of hCG administration for final oocyte maturation in IVF were analyzed retrospectively in Reproductive Medicine Center in First Affiliated Hospital of Nanjing Medical University. All stimulations were down-regulated with gronadotrophin release hormone agonist (GnRH-a) in both long protocols and short protocols before gonadotrophin stimulation. When the thresholds of serum progesterone were set at 5.5, 6.0, 6.5, 7.0, 7.5, 8.0, 8.5 and 9.0 nmol/L, respectively. If the level of progesterone was less than the thresholds, those patients were in lower progesterone group, on the contrary, more than the threshold value, those patients were in higher progesterone group. The laboratory results and the clinical outcomes between all patients at lower and higher progesterone group at different thresholds value were analyzed.

RESULTS

The rate of normal fertilization, quality embryos, successful implantation, chemical pregnancy, clinical pregnancy and live birth did not exhibit remarkable difference between patients with higher and lower serum progesterone level at multiple thresholds on the day of hCG administration in the 786 cycles (P > 0.05). However, when the thresholds of serum progesterone were at 8.5 and 9.0 nmol/L, early abortion rates of 27.3% (3/11) and 3/7 in higher progesterone group were significantly higher than 8.8% (26/297) and 8.6% (26/301) in lower progesterone group (P < 0.05). And the total abortion rates of 3/7 in higher progesterone group were significantly higher than 11.0% (34/301) in lower progesterone group when the thresholds of serum progesterone were 9.0 nmol/L (P < 0.05).

CONCLUSIONS

This study did not prove the correlationship between progesterone level at the day with hCG administration and the probability of clinical pregnancy or live birth. However, early abortion rates or the total abortion rates were associated with higher progesterone level when the thresholds of serum progesterone were at 8.5 nmol/L or 9.0 nmol/L.

Growth hormone for in vitro fertilization

BACKGROUND

In an effort to improve outcomes of in-vitro fertilisation cycles the use of growth hormone has been considered. Improving the outcomes of in-vitro fertilisation is especially important for subfertile women who are considered 'poor responders'.

OBJECTIVES

To assess the effectiveness of adjuvant growth hormone in in-vitro fertilisation protocols.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Groups trials register (June 2009), the Cochrane Central Register of Controlled Trials (Cochrane Library Issue 2, 2009), MEDLINE (1966 to June 2009), EMBASE (1988 to June 2009) and Biological Abstracts (1969 to June 2009).

SELECTION CRITERIA

All randomised controlled trials were included if they addressed the research question and provided outcome data for intervention and control participants.

DATA COLLECTION AND ANALYSIS

Assessment of trial risk of bias and extraction of relevant data was performed independently by two reviewers.

MAIN RESULTS

Ten studies (440 subfertile couples) were included. Results of the meta-analysis demonstrated no difference in outcome measures and adverse events in the routine use of adjuvant growth hormone in in-vitro fertilisation protocols. However, meta-analysis demonstrated a statistically significant difference in both live birth rates and pregnancy rates favouring the use of adjuvant growth hormone in in-vitro fertilisation protocols in women who are considered poor responders without increasing adverse events, OR 5.39, 95% CI 1.89 to 15.35 and OR 3.28, 95% CI 1.74 to 6.20 respectively.

AUTHORS' CONCLUSIONS

Although the use of growth hormone in poor responders has been found to show a significant improvement in live birth rates, we were unable to identify which sub-group of poor responders would benefit the most from adjuvant growth hormone. The result needs to be interpreted with caution, the included trials were few in number and small sample size. Therefore, before recommending growth hormone adjuvant in in-vitro fertilisation further research is necessary to fully define its role.

Oral contraceptive pill, progestogen or estrogen pre-treatment for ovarian stimulation protocols for women undergoing assisted reproductive techniques

BACKGROUND

For many subfertile women, assisted reproductive techniques (ART) is the only hope for a pregnancy and live birth. The combined oral contraceptive pill (OCP) given prior to the hormone therapy in an IVF cycle may result in better pregnancy outcomes of ART.

OBJECTIVES

To assess whether pre-treatment with combined OCPs, progestogens or estrogens in ovarian stimulation protocols affects outcomes in subfertile couples undergoing ART.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, PsycINFO. Other electronic resources on the Internet, reference list of relevant articles were also searched as well as the ESHRE abstracts (2008). All these searches were conducted in November 2008.

SELECTION CRITERIA

Randomised controlled trials of pre-treatment with combined OCP, progestogen or estrogen in subfertile women undergoing IVF/ICSI.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data and assessed risk of bias. We calculated Peto odds ratios for dichotomous data and weighted mean difference for continuous variables. Authors of trials were contacted in case of missing data.

MAIN RESULTS

No evidence of effect was found with regard to the number of live births when using a pre-treatment. However, the combined OCP in GnRH antagonist cycles, compared to no pre-treatment, is associated with fewer clinical pregnancies (Peto OR 0.69, P = 0.03) and more days and a higher amount of gonadotrophin therapy (respectively: MD 1.44, P < 0.00001; and MD 691.69, P < 0.00001). Also compared to placebo or no pre-treatment, a progestogen pre-treatment in GnRH agonist cycles, is associated with more clinical pregnancies (Peto OR 1.95, P = 0.007) and fewer ovarian cysts (Peto OR 0.21, P < 0.00001). At last, in estrogen pre-treated GnRH antagonist cycles, compared to no pre-treatment, more oocytes are retrieved (MD 2.01, P < 0.00001), but a higher amount of gonadotrophin therapy is needed (MD 207.08, P < 0.00001). For the other outcomes no evidence of effect was found or there were not enough studies available in the subgroup for pooling.

AUTHORS' CONCLUSIONS

There was evidence of improved pregnancy outcomes with progestogen pre-treatment and poorer pregnancy outcomes with a combined OCP pre-treatment. However, we conclude that major changes in ART protocols should not be made at this time, since the number of overall studies in the subgroups is small and reporting of the major outcomes is inadequate.

Insulin-sensitising drugs (metformin, rosiglitazone, pioglitazone, D-chiro-inositol) for women with polycystic ovary syndrome, oligo amenorrhoea and subfertility

BACKGROUND

Polycystic ovary syndrome (PCOS) is characterised by anovulation, hyperandrogaenemia and insulin resistance. Hyperinsulinaemia is associated with an increase in cardiovascular risk and the development of diabetes mellitus. If insulin sensitising agents such as metformin are effective in treating features of PCOS, then they could have wider health benefits than just treating the symptoms of the syndrome.

OBJECTIVES

To assess the effectiveness of insulin sensitising drugs in improving reproductive outcomes and metabolic parameters for women with PCOS and menstrual disturbance.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders & Subfertility Group trials register (searched September 2008), the Cochrane Central Register of Controlled Trials (Cochrane Library, third Quarter 2008), CINAHL (searched September 2008), MEDLINE (January 1966 to September 2008), and EMBASE (January 1985 to September 2008). All searches were rerun 13 August 2009 17 RCTs were located and await classification.

SELECTION CRITERIA

Randomised controlled trials which investigated the effect of insulin sensitising drugs compared with either placebo or no treatment, or compared with an ovulation induction agent.

DATA COLLECTION AND ANALYSIS

Thirty one trials (2537 women) were included for analysis, 27 of them using metformin and involving 2150 women.

MAIN RESULTS

There is no evidence that metformin improves live birth rates whether it is used alone (Pooled OR = 1.00, 95% CI 0.16 to 6.39) or in combination with clomiphene (Pooled OR = 1.48, 95% CI 1.12 to 1.95). However, clinical pregnancy rates are improved for metformin versus placebo (Pooled OR = OR 3.86, 95% C.I. 2.18 to 6.84) and for metformin and clomiphene versus clomiphene alone (Pooled OR =1.48, 95% C.I. 1.12 to 1.95) ). In the studies that compared metformin and clomiphene alone, there was no evidence of an improved live birth rate (OR= 0.67, 95% CI 0.44 to 1.02) but the pooled OR resulted in improved clinical pregnancy rate in in the clomiphene group (OR = 0.63 , 95% 0.43 to 0.92), although there was significant heterogeneity.There is also evidence that ovulation rates are improved with metformin in women with PCOS for metformin versus placebo (Pooled OR 2.12, 95% CI 1.50 to 3.0) and for metformin and clomiphene versus clomiphene alone (Pooled OR = 3.46, 95% CI 1.97 to 6.07).Metformin was also associated with a significantly higher incidence of gastrointestinal disturbance, but no serious adverse effects were reported.

AUTHORS' CONCLUSIONS

In agreement with the previous review, metformin is still of benefit in improving clinical pregnancy and ovulation rates. However, there is no evidence that metformin improves live birth rates whether it is used alone or in combination with clomiphene, or when compared with clomiphene. Therefore, the use of metformin in improving reproductive outcomes in women with PCOS appears to be limited.

Clomiphene citrate for unexplained subfertility in women

BACKGROUND

The effectiveness of clomiphene citrate has been demonstrated in the treatment of subfertility associated with infrequent or irregular ovulation. The physiologic effects and clinical benefits in ovulatory women with unexplained subfertility are less clear. The drug is associated with an increased risk of multiple pregnancy and a suggestion of potentially increased ovarian cancer risks. In light of these concerns, defining the effectiveness of clomiphene citrate for ovulatory women with unexplained subfertility is extremely important.

OBJECTIVES

To determine the effectiveness of clomiphene citrate in improving pregnancy outcomes in women with unexplained subfertility, used in a dose range of 50 to 250 mg for up to 10 days. The primary outcome was live births.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register (June 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 2), MEDLINE (1966 to June 2009), EMBASE (1980 to June 2009) and reference lists of articles.

SELECTION CRITERIA

Only randomised controlled trials were included. Quasi-randomised designs were excluded.

DATA COLLECTION AND ANALYSIS

Fourteen potentially relevant trials were identified of which seven were included in this review. All trials were assessed for risk of bias using standardised Menstrual Disorders and Subfertility Group methodology.

MAIN RESULTS

Data relating to 1159 participants from seven trials were collated. There was no evidence that clomiphene citrate was more effective than no treatment or placebo for live birth (odds ratio (OR) 0.79, 95% CI 0.45 to 1.38; P = 0.41) or for clinical pregnancy per woman randomised both with intrauterine insemination (IUI) (OR 2.40, 95% CI 0.70 to 8.19; P = 0.16), without IUI (OR 1.03, 95% CI 0.64 to 1.66; P = 0.91) and without IUI but using human chorionic gonadotropin (hCG) (OR 1.66, 95% CI 0.56 to 4.80; P = 0.35). It should be noted that heterogeneity between studies ranged from 34% to 58% using the I(2) statistic.

AUTHORS' CONCLUSIONS

There is no evidence of clinical benefit of clomiphene citrate for unexplained fertility. When making this treatment choice, potential side effects should be discussed. These include the increased risk of multiple pregnancy and the concern that use for more that 12 cycles has been associated with a three-fold increase in risk of ovarian cancer.

Endometrial preparation for women undergoing embryo transfer with frozen embryos or embryos derived from donor oocytes

BACKGROUND

If a fresh embryo, assisted reproductive technology procedure cycle is unsuccessful and there are frozen embryos available, a frozen-thawed embryo transfer is performed. In some specific cases women may undergo oocyte donation treatment. In both situations the endometrium is primed by the administration of estrogen and progesterone. To prevent the possibility of spontaneous ovulation, gonadotropin-releasing hormone (GnRH) agonists are frequently used.

OBJECTIVES

To evaluate the most effective endometrial preparation for women undergoing transfer with frozen embryos or embryos from donor oocytes with regard to the subsequent live birth rate.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, LILACS, and abstracts of reproductive societies' meetings (from inception). No language restrictions were applied. Experts in the field were contacted.

SELECTION CRITERIA

Randomised controlled trials evaluating endometrial preparation in women undergoing fresh donor cycles and frozen embryo transfers.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied the inclusion criteria, assessed trial risk of bias, and extracted data.

MAIN RESULTS

Twenty two randomised controlled trials were included. Five studies analysed the use of a GnRH agonist versus control. No significant benefit was demonstrated when using GnRH agonists. No evidence of statistically significant benefit was found for one GnRH agonist over another, or vaginal over intramuscular progesterone administration. No difference in pregnancy rate was demonstrated when no treatment was compared to aspirin, steroids, ovarian stimulation, or human chorionic gonadotropin (hCG) prior to embryo transfer, although using hCG several times before the oocyte retrieval decreases the pregnancy rate. Finally, when oocyte recipients were studied further, starting progesterone on the day of oocyte pick-up (OPU) or the day after OPU produced a significantly higher pregnancy rate (OR 1.87, 95% CI 1.13 to 3.08) than when recipients started progesterone the day prior to OPU.

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend any one particular protocol for endometrial preparation over another with regard to pregnancy rates after embryo transfers. These were either frozen embryos or embryos derived from donor oocytes. However, there is evidence of a lower pregnancy rate and a higher cycle cancellation rate when the progesterone supplementation is commenced prior to oocyte retrieval in oocyte donation cycles. Adequately powered studies are needed to evaluate each treatment more accurately.

Effect of seminal plasma on uterine inflammation, contractility and pregnancy rates in mares

REASONS FOR PERFORMING STUDY

There is conflicting evidence over the role seminal plasma plays in sperm transport and inflammation within the uterus of mares. In in vitro studies, seminal plasma has been shown to reduce polymorphonuclear neutrophil (PMN) function, but the opposite effect on uterine inflammation has been reported in vivo.

OBJECTIVES

To study the effect of seminal plasma on uterine contractility, inflammation and pregnancy rates by inseminating mares with low doses of sperm free from seminal plasma (Group 1) and containing seminal plasma (Group 2).

METHODS

Synchronised mares were inseminated with 50 x 10(6) sperm in either skim milk extender or seminal plasma. Uterine lavage was performed 6 h after insemination to assess the inflammatory response. The contraction frequency of the uterus was measured over a 4 min period 10 mins and 6 h after insemination, using B-mode ultrasonography. Pregnancy rates were assessed 16 days after insemination.

RESULTS

Uterine contractions were less frequent in Group 1 mares inseminated with seminal plasma and significantly more PMNs were found in the lavage fluid of those mares. Pregnancy rates were identical in both groups (62%).

CONCLUSIONS

This study provides evidence that seminal plasma decreases uterine contractility and increases the inflammatory response of the uterus to semen. No effect of seminal plasma on pregnancy rates was demonstrated.

POTENTIAL RELEVANCE

Mares that develop persistent mating-induced endometritis may have inherently poor uterine contractility and impaired uterine clearance. The presence of seminal plasma during breeding may not be desirable in these mares. The role of seminal plasma in problem mares warrants additional study.