1
|
Feferkorn I, Santos-Ribeiro S, Ubaldi FM, Velasco JG, Ata B, Blockeel C, Conforti A, Esteves SC, Fatemi HM, Gianaroli L, Grynberg M, Humaidan P, Lainas GT, La Marca A, Craig LB, Lathi R, Norman RJ, Orvieto R, Paulson R, Pellicer A, Polyzos NP, Roque M, Sunkara SK, Tan SL, Urman B, Venetis C, Weissman A, Yarali H, Dahan MH. The HERA (Hyper-response Risk Assessment) Delphi consensus for the management of hyper-responders in in vitro fertilization. J Assist Reprod Genet 2023; 40:2681-2695. [PMID: 37713144 PMCID: PMC10643792 DOI: 10.1007/s10815-023-02918-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 08/15/2023] [Indexed: 09/16/2023] Open
Abstract
PURPOSE To provide agreed-upon guidelines on the management of a hyper-responsive patient undergoing ovarian stimulation (OS) METHODS: A literature search was performed regarding the management of hyper-response to OS for assisted reproductive technology. A scientific committee consisting of 4 experts discussed, amended, and selected the final statements. A priori, it was decided that consensus would be reached when ≥66% of the participants agreed, and ≤3 rounds would be used to obtain this consensus. A total of 28/31 experts responded (selected for global coverage), anonymous to each other. RESULTS A total of 26/28 statements reached consensus. The most relevant are summarized here. The target number of oocytes to be collected in a stimulation cycle for IVF in an anticipated hyper-responder is 15-19 (89.3% consensus). For a potential hyper-responder, it is preferable to achieve a hyper-response and freeze all than aim for a fresh transfer (71.4% consensus). GnRH agonists should be avoided for pituitary suppression in anticipated hyper-responders performing IVF (96.4% consensus). The preferred starting dose in the first IVF stimulation cycle of an anticipated hyper-responder of average weight is 150 IU/day (82.1% consensus). ICoasting in order to decrease the risk of OHSS should not be used (89.7% consensus). Metformin should be added before/during ovarian stimulation to anticipated hyper-responders only if the patient has PCOS and is insulin resistant (82.1% consensus). In the case of a hyper-response, a dopaminergic agent should be used only if hCG will be used as a trigger (including dual/double trigger) with or without a fresh transfer (67.9% consensus). After using a GnRH agonist trigger due to a perceived risk of OHSS, luteal phase rescue with hCG and an attempt of a fresh transfer is discouraged regardless of the number of oocytes collected (72.4% consensus). The choice of the FET protocol is not influenced by the fact that the patient is a hyper-responder (82.8% consensus). In the cases of freeze all due to OHSS risk, a FET cycle can be performed in the immediate first menstrual cycle (92.9% consensus). CONCLUSION These guidelines for the management of hyper-response can be useful for tailoring patient care and for harmonizing future research.
Collapse
Affiliation(s)
- I Feferkorn
- IVF Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | | | - F M Ubaldi
- GeneraLife Centers for Reproductive Medicine, Rome, Italy
| | | | - B Ata
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Koc University School of Medicine, Istanbul, Turkey
- ART Fertility Clinics, Dubai, United Arab Emirates
| | - C Blockeel
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Jette, Belgium
| | - A Conforti
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - S C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Av. Dr. Heitor Penteado 1464, Campinas, SP, 13075-460, Brazil
- Department of Surgery (Division of Urology), University of Campinas (UNICAMP), Campinas, SP, Brazil
- Faculty of Health, Aarhus University, C, 8000, Aarhus, Denmark
| | - H M Fatemi
- ART Fertility Clinics, Abu Dhabi, United Arab Emirates
| | - L Gianaroli
- Società Italiana Studi di Medicina della Riproduzione, S.I.S.Me.R. Reproductive Medicine Institute, Bologna, Emilia-Romagna, Italy
| | - M Grynberg
- Department of Reproductive Medicine, Hôpital Antoine-Béclère, University Paris-Sud (Paris XI), Le Kremlin-Bicêtre, Clamart, France
| | - P Humaidan
- The Fertility Clinic, Skive Regional Hospital, Faculty of Health, Aarhus University, Resenvej 25, 7800, Skive, Denmark
| | | | - A La Marca
- Obstetrics, Gynecology and Reproductive Medicine, University of Modena and Reggio Emilia, Policlinico di Modena, via del Pozzo 71, 41124, Modena, Italy
| | - L B Craig
- Section of Reproductive Endocrinology & Infertility, Department of Obstetrics & Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, USA
| | - R Lathi
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University, Stanford, CA, USA
| | - R J Norman
- Robinson Research Institute, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
- FertilitySA, Adelaide, South Australia, Australia
- Monash Centre for Health Research and Implementation MCHRI, Monash University, Melbourne, Australia
- NHMRC Centre of Research Excellence in Women's Health in Reproductive Life (CRE-WHiRL), Melbourne, Australia
| | - R Orvieto
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center (Tel Hashomer), Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Tarnesby-Tarnowski Chair for Family Planning and Fertility Regulation, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - R Paulson
- University of Southern California, Los Angeles, CA, 90033, USA
| | - A Pellicer
- Department of Pediatrics, Obstetrics and Gynecology, School of Medicine, University of Valencia, Valencia, Spain
- IVI Roma Parioli, IVI-RMA Global, Rome, Italy
| | - N P Polyzos
- Department of Reproductive Medicine, Dexeus Mujer, Hospital Universitario Dexeus, Barcelona, Spain
| | - M Roque
- Department of Reproductive Medicine, ORIGEN-Center for Reproductive Medicine, Rio de Janeiro, RJ, Brazil
- Department of Obstetrics and Gynecology, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - S K Sunkara
- Department of Women and Children's Health, King's College London, London, UK
| | - S L Tan
- OriginElle Fertility Clinic 2110 Boul. Decarie, Montreal, QC, Canada
| | - B Urman
- Department of Obstetrics and Gynecology and Assisted Reproduction, American Hospital, Istanbul, Koc University School of Medicine, Istanbul, Turkey
| | - C Venetis
- Unit for Human Reproduction, 1st Dept of OB/Gyn, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Centre for Big Data Research in Health, Faculty of Medicine & Health, University of New South Wales, Sydney, New South Wales, Australia
- Virtus Health, Sydney, Australia
| | - A Weissman
- In Vitro Fertilization Unit, Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - H Yarali
- Division of Reproductive Endocrinology and Infertility, Dept. of Obstetrics and Gynecology, Hacettepe University, School of Medicine, Anatolia IVF and Women's Health Center, Ankara, Turkey
| | - M H Dahan
- Division of Reproductive Endocrinology and Infertility, McGill University Health Care Center, 888 Boul. de Maisonneuve E #200, Montreal, QC, H2L 4S8, Canada
| |
Collapse
|
2
|
Drakopoulos P, Khalaf Y, Esteves SC, Polyzos NP, Sunkara SK, Shapiro D, Rizk B, Ye H, Costello M, Koloda Y, Salle B, Lispi M, D'Hooghe T, La Marca A. Treatment algorithms for high responders: What we can learn from randomized controlled trials, real-world data and models. Best Pract Res Clin Obstet Gynaecol 2023; 86:102301. [PMID: 36646567 DOI: 10.1016/j.bpobgyn.2022.102301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 12/19/2022] [Indexed: 12/28/2022]
Abstract
A high ovarian response to conventional ovarian stimulation (OS) is characterized by an increased number of follicles and/or oocytes compared with a normal response (10-15 oocytes retrieved). According to current definitions, a high response can be diagnosed before oocyte pick-up when >18-20 follicles ≥11-12 mm are observed on the day of ovulation triggering; high response can be diagnosed after oocyte pick-up when >18-20 oocytes have been retrieved. Women with a high response are also at high risk of early ovarian hyper-stimulation syndrome (OHSS)/or late OHSS after fresh embryo transfers. Women at risk of high response can be diagnosed before stimulation based on several indices, including ovarian reserve markers (anti-Müllerian hormone [AMH] and antral follicle count [AFC], with cutoff values indicative of a high response in patients with PCOS of >3.4 ng/mL for AMH and >24 for AFC). Owing to the high proportion of high responders who are at the risk of developing OHSS (up to 30%), this educational article provides a framework for the identification and management of patients who fall into this category. The risk of high response can be greatly reduced through appropriate management, such as individualized choice of the gonadotropin starting dose, dose adjustment based on hormonal and ultrasound monitoring during OS, the choice of down-regulation protocol and ovulation trigger, and the choice between fresh or elective frozen embryo transfer. Appropriate management strategies still need to be defined for women who are predicted to have a high response and those who have an unexpected high response after starting treatment.
Collapse
Affiliation(s)
- Panagiotis Drakopoulos
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium; Department of Obstetrics and Gynaecology, University of Alexandria, Alexandria, 21526, Egypt.
| | - Yakoub Khalaf
- Reproductive Medicine and Surgery, Guy's and St Thomas' NHS Foundation Trust, King's College London, London, United Kingdom
| | - Sandro C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Campinas, Brazil; Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Nikolaos P Polyzos
- Department of Reproductive Medicine, Dexeus University Hospital, 08028, Barcelona, Spain; Faculty of Medicine and Health Sciences, University of Ghent (UZ Gent), 9000, Gent, Belgium
| | - Sesh K Sunkara
- Department of Women's Health, Faculty of Life Sciences and Medicine, King's College London, Great Maze Pond, London, United Kingdom
| | | | - Botros Rizk
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of South Alabama, Mobile, AL, 36604, USA
| | - Hong Ye
- Chongqing Key Laboratory of Human Embryo Engineering, Chongqing, China; Chongqing Clinical Research Center for Reproductive Medicine, Chongqing, China; Reproductive and Genetic Institute, Chongqing Health Center for Women and Children, No. 64 Jin Tang Street, Yu Zhong District, Chongqing, 400013, China
| | - Michael Costello
- Division of Obstetrics & Gynaecology, School of Women's and Children's Health, UNSW and Royal Hospital for Women and Monash IVF, Sydney, Australia
| | - Yulia Koloda
- Center of Reproduction "Life Line", Moscow, Russia; Department of Obstetrics and Gynecology, Russian Medical Academy of Continuous Professional Education, Moscow, Russia
| | - Bruno Salle
- Department of Reproductive Medicine, CHU Lyon, Hôpital Femme Mère Enfant, 59 Bd Pinel, 69500, Bron, France; Université Claude Bernard, Faculté de Médecine Lyon Sud, 165 Chemin Du Petit Revoyet, Oullins, France; INSERM Unité, 1208, 18 Avenue Doyen Lépine, Bron, France
| | - Monica Lispi
- Merck Healthcare KGaA, Darmstadt, Germany; PhD School of Clinical and Experimental Medicine, Unit of Endocrinology, University of Modena and Reggio Emilia, Italy
| | - Thomas D'Hooghe
- Merck Healthcare KGaA, Darmstadt, Germany; Department of Development and Regeneration, Laboratory of Endometrium, Endometriosis & Reproductive Medicine, KU Leuven, Leuven, Belgium; Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University Medical School, New Haven, USA
| | - Antonio La Marca
- Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, and Clinica Eugin, Modena, Italy
| |
Collapse
|
3
|
ELhelw EM, El Serour AGEA, Rady MS, Abdeltawab A. Freeze-all policy versus luteal phase support with low dose of human chorionic gonadotrophin for high-responder patients undergoing intracytoplasmic sperm injection on pregnancy outcomes: a retrospective cohort observational study. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2022. [DOI: 10.1186/s43043-022-00113-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The literature has always controversies on the use of freeze-all policy in high-responder women performing intracytoplasmic sperm injection. In this article, we discuss the benefits of freeze-all policy on the incidence of pregnancy outcomes and the complications.
The main body of abstract
Freeze-all policy is applied to the intracytoplasmic sperm injection program by freezing of all embryos and delaying embryo transfer to another subsequent ovarian cycle, to decrease the incidence of ovarian hyperstimulation syndrome, especially in high-responder women. Unfortunately, freeze-all policy is correlated with an increase in the economic costs and more ICSI laboratory effort. Delayed embryo transfer (ET) is correlated with more anxiety among the patients. An alternative strategy is to perform fresh embryo transfer with more intensive luteal phase support to compensate for the negative effect of the GnRH agonist on the endometrial receptivity and luteal phase support.
Short conclusion
The freeze-all policy had better pregnancy rates with less incidence of moderate to severe hyperstimulation syndrome compared with original fresh embryo transfer in high-responder women performing intracytoplasmic sperm injection.
Collapse
|
4
|
Zhao J, Hao J, Li Y. Individualized luteal phase support after fresh embryo transfer: unanswered questions, a review. Reprod Health 2022; 19:19. [PMID: 35065655 PMCID: PMC8783459 DOI: 10.1186/s12978-021-01320-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 12/23/2021] [Indexed: 12/20/2022] Open
Abstract
Background Luteal phase support (LPS) is an important part of assisted reproductive technology (ART), and adequate LPS is crucial for embryo implantation. At present, a great number of studies have put emphasis on an individualized approach to controlled ovarian stimulation (COS) and endometrium preparation of frozen- thawed embryo transfer (FET); However, not much attention has been devoted to the luteal phase and almost all ART cycles used similar LPS protocol bases on experience. Main body This review aims to concisely summarize individualized LPS protocols in fresh embryo transfer cycles with hCG trigger or GnRH-a trigger. The PubMed and Google Scholar databases were searched using the keywords: (luteal phase support or LPS) AND (assisted reproductive technology or ART or in vitro fertilization or IVF). We performed comprehensive literature searches in the English language describing the luteal phase support after ART, since 1978 and ending in May 2019. Recent studies have shown that many modified LPS programs were used in ART cycle. In the cycle using hCG for final oocyte maturation, the progesterone with or without low dose of hCG may be adequate to maintain pregnancy. In the cycle using GnRH-a for trigger, individualized low dose of hCG administration with or without progesterone was suggested. The optimal timing to start the LPS would be between 24 and 72 h after oocyte retrieval and should last at least until the pregnancy test is positive. Addition of E2 and the routes of progesterone administration bring no beneficial effect on the outcomes after ART. Conclusions Individualized LPS should be applied, according to the treatment protocol, the patients’ specific characteristics, and desires. Luteal phase support (LPS) is an important part of assisted reproductive technology (ART). In the cycle using hCG for final oocyte maturation, the progesterone with or without low dose of hCG may be adequate to maintain pregnancy. In the cycle using GnRH-a for trigger, individualized low dose of hCG administration with or without progesterone was suggested. The optimal timing to start the LPS would be between 24 and 72 h after oocyte retrieval and should last at least until the pregnancy test is positive. Addition of E2 and the routes of progesterone administration bring no beneficial effect on the outcomes after ART. Individualized LPS should be applied, according to the treatment protocol, the patients’ specific characteristics, and desires.
Collapse
Affiliation(s)
- Jing Zhao
- Reproductive Medicine Center, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha City, Hunan Province, People's Republic of China.,Clinical Research Center For Women's Reproductive Health In Hunan Province, Hunan, People's Republic of China
| | - Jie Hao
- Reproductive Medicine Center, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha City, Hunan Province, People's Republic of China.,Clinical Research Center For Women's Reproductive Health In Hunan Province, Hunan, People's Republic of China
| | - Yanping Li
- Reproductive Medicine Center, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha City, Hunan Province, People's Republic of China. .,Clinical Research Center For Women's Reproductive Health In Hunan Province, Hunan, People's Republic of China.
| |
Collapse
|
5
|
Cao M, Liu Z, Lin Y, Luo Y, Li S, Huang Q, Liu H, Liu J. A Personalized Management Approach of OHSS: Development of a Multiphase Prediction Model and Smartphone-Based App. Front Endocrinol (Lausanne) 2022; 13:911225. [PMID: 35872996 PMCID: PMC9296830 DOI: 10.3389/fendo.2022.911225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE This study aimed to develop multiphase big-data-based prediction models of ovarian hyperstimulation syndrome (OHSS) and a smartphone app for risk calculation and patients' self-monitoring. METHODS Multiphase prediction models were developed from a retrospective cohort database of 21,566 women from January 2017 to December 2020 with controlled ovarian stimulation (COS). There were 17,445 women included in the final data analysis. Women were randomly assigned to either training cohort (n = 12,211) or validation cohort (n = 5,234). Their baseline clinical characteristics, COS-related characteristics, and embryo information were evaluated. The prediction models were divided into four phases: 1) prior to COS, 2) on the day of ovulation trigger, 3) after oocyte retrieval, and 4) prior to embryo transfer. The multiphase prediction models were built with stepwise regression and confirmed with LASSO regression. Internal validations were performed using the validation cohort and were assessed by discrimination and calibration, as well as clinical decision curves. A smartphone-based app "OHSS monitor" was constructed as part of the built-in app of the IVF-aid platform. The app had three modules, risk prediction module, symptom monitoring module, and treatment monitoring module. RESULTS The multiphase prediction models were developed with acceptable distinguishing ability to identify OHSS at-risk patients. The C-statistics of the first, second, third, and fourth phases in the training cohort were 0.628 (95% CI 0.598-0.658), 0.715 (95% CI 0.688-0.742), 0.792 (95% CI 0.770-0.815), and 0.814 (95% CI 0.793-0.834), respectively. The calibration plot showed the agreement of predictive and observed risks of OHSS, especially at the third- and fourth-phase prediction models in both training and validation cohorts. The net clinical benefits of the multiphase prediction models were also confirmed with a clinical decision curve. A smartphone-based app was constructed as a risk calculator based on the multiphase prediction models, and also as a self-monitoring tool for patients at risk. CONCLUSIONS We have built multiphase prediction models based on big data and constructed a user-friendly smartphone-based app for the personalized management of women at risk of moderate/severe OHSS. The multiphase prediction models and user-friendly app can be readily used in clinical practice for clinical decision-support and self-management of patients.
Collapse
Affiliation(s)
- Mingzhu Cao
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Key Laboratory for Reproductive Medicine of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhi Liu
- Department of Ultrasound, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yanshan Lin
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Key Laboratory for Reproductive Medicine of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yiqun Luo
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Key Laboratory for Reproductive Medicine of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Sichen Li
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Key Laboratory for Reproductive Medicine of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qing Huang
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Key Laboratory for Reproductive Medicine of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Haiying Liu
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Key Laboratory for Reproductive Medicine of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- *Correspondence: Haiying Liu, ; Jianqiao Liu,
| | - Jianqiao Liu
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Key Laboratory for Reproductive Medicine of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- *Correspondence: Haiying Liu, ; Jianqiao Liu,
| |
Collapse
|
6
|
Abdulkhalikova D, Bokal EV, Stimpfel M, Ciglar P, Korosec S. Reproductive Outcome After GnRH Agonist Triggering With Co-Administration of 1500 IU hCG on the Day of Oocyte Retrieval in High Responders: A Long-Term Retrospective Cohort Study. Front Endocrinol (Lausanne) 2022; 13:826411. [PMID: 35464066 PMCID: PMC9019487 DOI: 10.3389/fendo.2022.826411] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/02/2022] [Indexed: 11/13/2022] Open
Abstract
UNLABELLED While triggering oocyte maturation with GnRH agonist (GnRHa) seems to be safe and effective in terms of the risk of developing OHSS and the number of metaphase II oocytes, it nevertheless results in luteal phase deficiency. To date, strategies have been developed in order to rescue defective luteal phase of GnRHa triggered cycles. Our study aimed to assess the reproductive outcome of GnRHa triggered cycles combined with modified luteal support (1500 IU hCG at the day of oocyte retrieval) in women with high ovarian response and to compare the outcome with hCG triggered cycles in GnRH antagonist IVF-ICSI procedures. A retrospective cohort database review of the results of GnRH antagonist IVF-ICSI cycles was conducted at a tertiary-care IVF center in Ljubljana, Slovenia. A total of 6126 cycles, performed from January 1, 2014, to December 31, 2020, were included in the final analysis. Final oocyte maturation was performed with either 5000, 6500, or 10,000 IU hCG (women with normal ovarian response) or 0.6 mg GnRHa (buserelin), supplemented with 1500 IU hCG on the day of oocyte retrieval (in women with high ovarian response). In cases of excessive ovarian response and/or high risk of OHSS luteal support was not introduced and all good quality blastocysts were frozen. According to significant differences in patients' age and the number of oocytes in the two groups, matching by age and number of oocytes was performed. No significant differences were observed regarding pregnancy rate per embryo transfer, rate of early pregnancy loss, and livebirth rate per pregnancy between the GnRHa and hCG trigger groups, respectively. A significant difference in the number of developed embryos and blastocysts, as well as the number of frozen blastocysts, was seen in favor of the GnRHa trigger. However, the birth weight in the GnRHa trigger group was significantly lower. CONCLUSION The results of our study support the use of GnRHa for final oocyte maturation in GnRH antagonist IVF cycles in women with high ovarian response. Luteal phase rescue was performed by co-administration of 1500 IU hCG on the day of oocyte retrieval and estradiol and progesterone supplementation. In our experience, such an approach results in a comparable reproductive outcome with hCG trigger group.
Collapse
Affiliation(s)
- Dzhamilyat Abdulkhalikova
- Division of Obstetrics and Gynaecology, Department of Human Reproduction, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Eda Vrtacnik Bokal
- Division of Obstetrics and Gynaecology, Department of Human Reproduction, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Martin Stimpfel
- Division of Obstetrics and Gynaecology, Department of Human Reproduction, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Primoz Ciglar
- Department of Gynaecology and Obstetrics, Ptuj General Hospital, Ptuj, Slovenia
| | - Sara Korosec
- Division of Obstetrics and Gynaecology, Department of Human Reproduction, University Medical Centre Ljubljana, Ljubljana, Slovenia
- *Correspondence: Sara Korosec,
| |
Collapse
|
7
|
Ghunaim S, Khalife D, Taha L, Odeh O, Habr N, Awwad J. Ovarian hyperstimulation syndrome following the use of GnRH agonist trigger of final oocyte maturation and freeze-all strategy: A case report and review of the literature. ASIAN PACIFIC JOURNAL OF REPRODUCTION 2022. [DOI: 10.4103/2305-0500.356846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
8
|
Gonadotropin-Releasing Hormone Agonist Versus Recombinant Human Chorionic Gonadotropin Triggering in Fertility Preservation Cycles. Reprod Sci 2021; 28:3390-3396. [PMID: 34076872 DOI: 10.1007/s43032-021-00622-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 05/13/2021] [Indexed: 10/21/2022]
Abstract
The purpose of this research is to study the efficacy of GnRH-a versus r-hCG triggering in patients who go through fertility preservation cycles. This retrospective cohort study was performed in a tertiary university-affiliated medical center. It includes 191 patients undergoing fertility preservation cycles between May 2013 and September 2018, in which ovulation was induced by either GnRH-a or r-hCG. Main outcome measures were number and rate of mature oocyte. Among treatment cycles with medical indication, GnRH agonist significantly increases the odds for high mature rate by 3.55 (1.30-9.66), while in treatment cycles with social indication, there is no significant effect of the triggering agent. An advantage for GnRH-a triggering was observed in medically indicated preservation cycles.
Collapse
|
9
|
Santos-Ribeiro S, Mackens S, Popovic-Todorovic B, Racca A, Polyzos NP, Van Landuyt L, Drakopoulos P, de Vos M, Tournaye H, Blockeel C. The freeze-all strategy versus agonist triggering with low-dose hCG for luteal phase support in IVF/ICSI for high responders: a randomized controlled trial. Hum Reprod 2021; 35:2808-2818. [PMID: 32964939 DOI: 10.1093/humrep/deaa226] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 07/19/2020] [Indexed: 12/13/2022] Open
Abstract
STUDY QUESTION Does the freeze-all strategy in high-responders increase pregnancy rates and improve safety outcomes when compared with GnRH agonist triggering followed by low-dose hCG intensified luteal support with a fresh embryo transfer? SUMMARY ANSWER Pregnancy rates after either fresh embryo transfer with intensified luteal phase support using low-dose hCG or the freeze-all strategy did not vary significantly; however, moderate-to-severe ovarian hyperstimulation syndrome (OHSS) occurred more frequently in the women who attempted a fresh embryo transfer. WHAT IS KNOWN ALREADY Two strategies following GnRH agonist triggering (the freeze-all approach and a fresh embryo transfer attempt using a low-dose of hCG for intensified luteal phase support) are safer alternatives when compared with conventional hCG triggering with similar pregnancy outcomes. However, these two strategies have never been compared head-to-head in an unrestricted predicted hyper-responder population. STUDY DESIGN, SIZE, DURATION This study included women with an excessive response to ovarian stimulation (≥18 follicles measuring ≥11 mm) undergoing IVF/ICSI in a GnRH antagonist suppressed cycle between 2014 and 2017. Our primary outcome was clinical pregnancy at 7 weeks after the first embryo transfer. Secondary outcomes included live birth and the development of moderate-to-severe OHSS. PARTICIPANTS/MATERIALS, SETTING, METHODS Following GnRH agonist triggering, women were randomized either to cryopreserve all good-quality embryos followed by a frozen embryo transfer in an subsequent artificial cycle or to perform a fresh embryo transfer with intensified luteal phase support (1500 IU hCG on the day of oocyte retrieval, plus oral estradiol 2 mg two times a day, plus 200 mg of micronized vaginal progesterone three times a day). MAIN RESULTS AND THE ROLE OF CHANCE A total of 212 patients (106 in each arm) were recruited in the study, with three patients (one in the fresh embryo transfer group and two in the freeze-all group) later withdrawing their consent to participate in the study. One patient in the freeze-all group became pregnant naturally (clinical pregnancy diagnosed 38 days after randomization) prior to the first frozen embryo transfer. The study arms did not vary significantly in terms of the number of oocytes retrieved and embryos produced/transferred. The intention to treat clinical pregnancy and live birth rates (with the latter excluding four cases lost to follow-up: one in the fresh transfer and three in the freeze-all arms, respectively) after the first embryo transfer did not vary significantly among the fresh embryo transfer and freeze-all study arms: 51/105 (48.6%) versus 57/104 (54.8%) and 41/104 (39.4%) versus 42/101 (41.6%), respectively (relative risk for clinical pregnancy 1.13, 95% CI 0.87-1.47; P = 0.41). However, moderate-to-severe OHSS occurred solely in the group that received low-dose hCG (9/105, 8.6%, 95% CI 3.2% to 13.9% vs 0/104, 95% CI 0 to 3.7, P < 0.01). LIMITATIONS, REASONS FOR CAUTION The sample size calculation was based on a 19% absolute difference in terms of clinical pregnancy rates, therefore smaller differences, as observed in the trial, cannot be reliably excluded as non-significant. WIDER IMPLICATIONS OF THE FINDINGS This study offers the first comparative analysis of two common strategies applied to women performing IVF/ICSI with a high risk to develop OHSS. While pregnancy rates did not vary significantly, a fresh embryo transfer with intensified luteal phase support may still not avoid the risk of moderate-to-severe OHSS and serious consideration should be made before recommending it as a routine first-line treatment. Future trials may allow us to confirm these findings. STUDY FUNDING/COMPETING INTEREST(S) The authors have no conflicts of interest to disclose. No external funding was obtained for this study. TRIAL REGISTRATION NUMBER ClinicalTrials.gov identifier NCT02148393. TRIAL REGISTRATION DATE 28 May 2014. DATE OF FIRST PATIENT’S ENROLMENT 30 May 2014.
Collapse
Affiliation(s)
- Samuel Santos-Ribeiro
- IVIRMA Lisboa, Avenida Infante Dom Henrique 333 H 1-9, Lisbon, Portugal.,Department of Obstetrics and Gynecology, Faculty of Medicine, University of Lisbon, Lisboa, Portugal.,Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Shari Mackens
- Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | | | - Annalisa Racca
- Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Nikolaos P Polyzos
- Department of Obstetrics, Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain.,Department of Surgical and Clinical Science, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium.,Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Lisbet Van Landuyt
- Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Panagiotis Drakopoulos
- Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium.,Department of Surgical and Clinical Science, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Michel de Vos
- Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Herman Tournaye
- Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Christophe Blockeel
- Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium.,Department of Obstetrics and Gynaecology, School of Medicine, University of Zagreb, Zagreb, Croatia
| |
Collapse
|
10
|
Luteal Support with very Low Daily Dose of Human Chorionic Gonadotropin after Fresh Embryo Transfer as an Alternative to Cycle Segmentation for High Responders Patients Undergoing Gonadotropin-Releasing Hormone Agonist-Triggered IVF. Pharmaceuticals (Basel) 2021; 14:ph14030228. [PMID: 33800021 PMCID: PMC7998839 DOI: 10.3390/ph14030228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 11/16/2022] Open
Abstract
The segmentation of the in vitro fertilization (IVF) cycle, consisting of the freezing of all embryos and the postponement of embryo transfer (ET), has become popular in recent years, with the main purpose of preventing ovarian hyperstimulation syndrome (OHSS) in patients with high response to controlled ovarian stimulation (COS). Indeed cycle segmentation (CS), especially when coupled to a GnRH-agonist trigger, was shown to reduce the incidence of OHSS in high-risk patients. However, CS increases the economic costs and the work amount for IVF laboratories. An alternative strategy is to perform a fresh ET in association with intensive luteal phase pharmacological support, able to overcome the negative effects of the GnRH-agonist trigger on the luteal phase and on endometrial receptivity. In order to compare these two strategies, we performed a retrospective, real-life cohort study including 240 non-polycystic ovarian syndrome (PCO) women with expected high responsiveness to COS (AMH >2.5 ng/mL), who received either fresh ET plus 100 IU daily human chorionic gonadotropin (hCG) as luteal support (FRESH group, n = 133), or cycle segmentation with freezing of all embryos and postponed ET (CS group, n = 107). The primary outcomes were: implantation rate (IR), live birth rate (LBR) after the first ET, and incidence of OHSS. Overall, significantly higher IR and LBR were observed in the CS group than in the FRESH group (42.9% vs. 27.8%, p < 0.05 and 32.7% vs. 19.5%, p < 0.05, respectively); the superiority of CS strategy was particularly evident when 16-19 oocytes were retrieved (LBR 42.2% vs. 9.5%, p = 0.01). Mild OHSS appeared with the same incidence in the two groups, whereas moderate and severe OHSS forms were observed only in the FRESH group (1.5% and 0.8%, respectively). In conclusion, in non-PCO women, high responders submitted to COS with the GnRH-antagonist protocol and GnRH-agonist trigger, CS strategy was associated with higher IR and LBR than the strategy including fresh ET followed by luteal phase support with a low daily hCG dose. CS appears to be advisable, especially when >15 oocytes are retrieved.
Collapse
|
11
|
How frequent is severe ovarian hyperstimulation syndrome after GnRH agonist triggering in high-risk women? A systematic review and meta-analysis. Reprod Biomed Online 2020; 42:635-650. [PMID: 33483281 DOI: 10.1016/j.rbmo.2020.11.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 10/27/2020] [Accepted: 11/08/2020] [Indexed: 01/11/2023]
Abstract
The aim of the present systematic review and meta-analysis was to assess the incidence of severe ovarian hyperstimulation syndrome (OHSS) after triggering of final oocyte maturation with gonadotrophin releasing hormone agonist (GnRHa) in high-risk women. The pooled incidence of severe OHSS in high-risk women who did not receive any form of luteal phase support was 0% (95% CI 0.0 to 0.0, I2 = 0%, random-effects model, 14 data sets, 983 women). The pooled incidence of severe OHSS in high-risk women in whom HCG was added to standard luteal phase support was 1% (95% CI 0.0 to 2.0, I2 = 27.02%, random-effects model, 10 data sets, 707 women). The incidence of severe OHSS in high-risk women triggered by a combination of GnRHa and HCG (dual triggering), who received standard luteal phase support, was 1% (95% CI 0.0 to 3.0, one study, 182 women). The incidence of severe OHSS in high-risk women, is not eliminated when HCG is administered either concomitantly with GnRHa (dual triggering), during the luteal phase after GnRHa triggering, or both. On the contrary, it is eliminated when no luteal support is administered.
Collapse
|
12
|
The freeze-all strategy after IVF: which indications? Reprod Biomed Online 2020; 42:529-545. [PMID: 33384269 DOI: 10.1016/j.rbmo.2020.11.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 10/09/2020] [Accepted: 11/18/2020] [Indexed: 12/21/2022]
Abstract
The freeze-all strategy is gaining popularity worldwide as an alternative to the conventional fresh embryo transfer. It consists of cryopreservation of the entire embryo cohort and the embryo transfer in a subsequent cycle that takes place separately from ovarian stimulation. The freeze-all strategy was initially a 'rescue' strategy for women at high risk of ovarian hyperstimulation syndrome; however, this approach has been extended to other indications as a scheduled strategy to improve implantation rates. This assumes that ovarian stimulation can alter endometrial receptivity in fresh cycles owing to the effect of supraphysiological levels of steroids on endometrial maturation. The procedure, however, has not been associated with increased live birth rates in all infertile couples, and concerns have been raised about the occurrence of several adverse perinatal outcomes. It is, therefore, crucial to identify in which subgroups of patients a freeze-all strategy could be beneficial. The aim of this review is to summarize current scientific research in this field to highlight potential indications for this strategy and to guide clinicians in their daily practice.
Collapse
|
13
|
Equivalent live-birth rate in antagonist IVF/ICSI protocol after oocyte triggering with GnRH agonist supplemented with 1500 r-hCG the day of oocyte retrieval vs r-hCG : A case-control study. J Gynecol Obstet Hum Reprod 2020; 49:101702. [DOI: 10.1016/j.jogoh.2020.101702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 01/26/2020] [Accepted: 01/29/2020] [Indexed: 11/17/2022]
|
14
|
Castillo JC, Haahr T, Martínez-Moya M, Humaidan P. Gonadotropin-releasing hormone agonist for ovulation trigger - OHSS prevention and use of modified luteal phase support for fresh embryo transfer. Ups J Med Sci 2020; 125:131-137. [PMID: 32366146 PMCID: PMC7721056 DOI: 10.1080/03009734.2020.1736696] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
The introduction of gonadotrophin-releasing hormone agonist (GnRHa) trigger greatly impacted modern IVF treatment. Patients at low risk of ovarian hyperstimulation syndrome (OHSS) development, undergoing fresh embryo transfer and GnRHa trigger can be offered a virtually OHSS-free treatment with non-inferior reproductive outcomes by using a modified luteal phase support in terms of small boluses of human chorionic gonadotrophin (hCG), daily recombinant luteinizing hormone LH (rLH) or GnRHa. In the OHSS risk patient, GnRHa trigger can safely be performed, followed by a 'freeze-all' policy with a minimal risk of OHSS development and high live birth rates in the subsequent frozen embryo transfer cycle. Importantly, GnRHa trigger opened the 'black box' of the luteal phase, promoting research in the most optimal steroid levels during the luteal phase. GnRHa trigger allows high-dose gonadotropin stimulation to achieve the optimal number of oocytes and embryos needed to ensure the highest chance of live birth. This review thoroughly discusses how the GnRHa trigger concept adds safety and efficacy to modern IVF in terms of OHSS prevention. Furthermore, the optimal luteal phase management after GnRHa trigger in fresh embryo transfer cycles is discussed.
Collapse
Affiliation(s)
- Juan Carlos Castillo
- Instituto Bernabeu, Alicante, Spain
- CONTACT Juan Carlos Castillo Instituto Bernabeu, Av. Albufereta 31, Alicante, 03016, Spain
| | - Thor Haahr
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- The Fertility Clinic Skive, Skive Regional Hospital, Skive, Denmark
| | | | - Peter Humaidan
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- The Fertility Clinic Skive, Skive Regional Hospital, Skive, Denmark
| |
Collapse
|
15
|
Hipp HS, Gaskins AJ, Nagy ZP, Capelouto SM, Shapiro DB, Spencer JB. Effect of oocyte donor stimulation on recipient outcomes: data from a US national donor oocyte bank. Hum Reprod 2020; 35:847-858. [PMID: 32142582 PMCID: PMC7192536 DOI: 10.1093/humrep/deaa003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 12/14/2019] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTION How does ovarian stimulation in an oocyte donor affect the IVF cycle and obstetric outcomes in recipients? SUMMARY ANSWER Higher donor oocyte yields may affect the proportion of usable embryos but do not affect live birth delivery rate or obstetric outcomes in oocyte recipients. WHAT IS KNOWN ALREADY In autologous oocyte fresh IVF cycles, the highest live birth delivery rates occur when ~15-25 oocytes are retrieved, with a decline thereafter, perhaps due to the hormone milieu, with super-physiologic estrogen levels. There are scant data in donor oocyte cycles, wherein the oocyte environment is separated from the uterine environment. STUDY DESIGN, SIZE, DURATION This was a retrospective cohort study from 2008 to 2015 of 350 oocyte donors who underwent a total of 553 ovarian stimulations and oocyte retrievals. The oocytes were vitrified and then distributed to 989 recipients who had 1745 embryo transfers. The primary outcome was live birth delivery rate, defined as the number of deliveries that resulted in at least one live birth per embryo transfer cycle. PARTICIPANTS/MATERIALS, SETTING, METHODS The study included oocyte donors and recipients at a donor oocyte bank, in collaboration with an academic reproductive endocrinology division. Donors with polycystic ovary syndrome and recipients who used gestational carriers were excluded. The donors all underwent conventional ovarian stimulation using antagonist protocols. None of the embryos underwent pre-implantation genetic testing. The average (mean) number of embryos transferred to recipients was 1.4 (range 1-3). MAIN RESULTS AND THE ROLE OF CHANCE Per ovarian stimulation cycle, the median number of oocytes retrieved was 30 (range: 9-95). Among the 1745 embryo transfer cycles, 856 of the cycles resulted in a live birth (49.1%). There were no associations between donor oocyte yield and probability of live birth, adjusting for donor age, BMI, race/ethnicity and retrieval year. The results were similar when analyzing by mature oocytes. Although donors with more oocytes retrieved had a higher number of developed embryos overall, there was a relatively lower percentage of usable embryos per oocyte warmed following fertilization and culture. In our model for the average donor in the data set, holding all variables constant, for each additional five oocytes retrieved, there was a 4% (95% CI 1%, 7%) lower odds of fertilization and 5% (95% CI 2%, 7%) lower odds of having a usable embryo per oocyte warmed. There were no associations between donor oocyte yield and risk of preterm delivery (<37 weeks gestation) and low birthweight (<2500 g) among singleton infants. LIMITATIONS, REASONS FOR CAUTION Ovarian stimulation was exclusively performed in oocyte donors. This was a retrospective study design, and we were therefore unable to ensure proportional exposure groups. These findings may not generalizable to older or less healthy women who may be vitrifying oocytes for planned fertility delay. There remain significant risks to aggressive ovarian stimulation, including ovarian hyperstimulation. In addition, long-term health outcomes of extreme ovarian stimulation are lacking. Lastly, we did not collect progesterone levels and are unable to evaluate the impact of rising progesterone on outcomes. WIDER IMPLICATIONS OF THE FINDINGS Live birth delivery rates remain high with varying amounts of oocytes retrieved in this donor oocyte model. In a vitrified oocyte bank setting, where oocytes are typically sent as a limited number cohort, recipients are not affected by oocyte yields. STUDY FUNDING/COMPETING INTEREST(S) Additional REDCap grant support at Emory was provided through UL1 TR000424. Dr. Audrey Gaskins was supported in part by a career development award from the NIEHS (R00ES026648).
Collapse
Affiliation(s)
- H S Hipp
- Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Emory University School of Medicine, 550 Peachtree Street, Atlanta, GA 30308, USA
| | - A J Gaskins
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA 30322, USA
| | - Z P Nagy
- Reproductive Biology Associates, 1100 Johnson Ferry Road, Sandy Springs, GA 30342, USA
| | - S M Capelouto
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - D B Shapiro
- Reproductive Biology Associates, 1100 Johnson Ferry Road, Sandy Springs, GA 30342, USA
| | - J B Spencer
- Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Emory University School of Medicine, 550 Peachtree Street, Atlanta, GA 30308, USA
| |
Collapse
|
16
|
Makhijani R, Thorne J, Bartels C, Bartolucci A, Nulsen J, Grow D, Benadiva C, Engmann L. Pregnancy outcomes after frozen-thawed single euploid blastocyst transfer following IVF cycles using GNRH agonist or HCG trigger for final oocyte maturation. J Assist Reprod Genet 2020; 37:611-617. [PMID: 31897845 DOI: 10.1007/s10815-019-01646-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 11/29/2019] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To assess whether GnRH agonist trigger impacts the implantation potential of euploid embryos. METHODS Retrospective cohort study done at an academic IVF center evaluating frozen-thawed embryo transfer (FET) cycles in which single-euploid blastocysts were transferred between 2014 and 2019. All embryos were generated in an IVF cycle which used GnRHa or hCG trigger and then were transferred in a programmed or natural FET cycle. Only the first FET cycle was included for each patient. Primary outcome was ongoing pregnancy rate or live birth rate (OPR/LBR). Secondary outcomes were implantation rate (IR), clinical pregnancy rate (CPR), clinical loss rate (CLR), and multiple pregnancy rate (MPR). Logistic regression was performed to control for confounding variables. A p value of < 0.05 was considered statistically significant. RESULTS Two hundred sixty-three FET cycles were included for analysis (GnRHa = 145; hCG = 118). The GnRHa group was significantly younger (35.2 vs. 37.5 years) and had higher AMH values (4.50 ng/ml vs. 2.03 ng/ml) than the hCG group, respectively (p < 0.05). There was no significant difference in OPR/LBR (64.1% (93/145) vs. 65.3% (77/118); p = 0.90) between the GnRHa and hCG groups, respectively. There was also no significant difference in IR, CPR, CLR, or MPR between groups. After controlling for confounding variables, the adjusted odds ratio for OPR/LBR was 0.941 (95% CI, 0.534-1.658); p = 0.83) comparing GnRHa to hCG. Pregnancy outcomes did not significantly differ when groups were stratified by age (< 35 vs. > 35 years old). CONCLUSIONS Our findings confirm that euploid embryos created after hCG or GnRHa trigger have the same potential for pregnancy.
Collapse
Affiliation(s)
- Reeva Makhijani
- Center for Advanced Reproductive Services, Division of Reproductive Endocrinology and Infertility, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Jeffrey Thorne
- Center for Advanced Reproductive Services, Division of Reproductive Endocrinology and Infertility, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Chantal Bartels
- Center for Advanced Reproductive Services, Division of Reproductive Endocrinology and Infertility, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Alison Bartolucci
- Center for Advanced Reproductive Services, Division of Reproductive Endocrinology and Infertility, University of Connecticut School of Medicine, Farmington, CT, USA
| | - John Nulsen
- Center for Advanced Reproductive Services, Division of Reproductive Endocrinology and Infertility, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Daniel Grow
- Center for Advanced Reproductive Services, Division of Reproductive Endocrinology and Infertility, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Claudio Benadiva
- Center for Advanced Reproductive Services, Division of Reproductive Endocrinology and Infertility, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Lawrence Engmann
- Center for Advanced Reproductive Services, Division of Reproductive Endocrinology and Infertility, University of Connecticut School of Medicine, Farmington, CT, USA.
| |
Collapse
|
17
|
Mizrachi Y, Horowitz E, Farhi J, Raziel A, Weissman A. Ovarian stimulation for freeze-all IVF cycles: a systematic review. Hum Reprod Update 2019; 26:118-135. [DOI: 10.1093/humupd/dmz037] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 09/07/2019] [Accepted: 09/23/2019] [Indexed: 12/30/2022] Open
Abstract
Abstract
BACKGROUND
Freeze-all IVF cycles are becoming increasingly prevalent for a variety of clinical indications. However, the actual treatment objectives and preferred treatment regimens for freeze-all cycles have not been clearly established.
OBJECTIVE AND RATIONALE
We aimed to conduct a systematic review of all aspects of ovarian stimulation for freeze-all cycles.
SEARCH METHODS
A comprehensive search in Medline, Embase and The Cochrane Library was performed. The search strategy included keywords related to freeze-all, cycle segmentation, cumulative live birth rate, preimplantation genetic diagnosis, preimplantation genetic testing for aneuploidy, fertility preservation, oocyte donation and frozen-thawed embryo transfer. We included relevant studies published in English from 2000 to 2018.
OUTCOMES
Our search generated 3292 records. Overall, 69 articles were included in the final review. Good-quality evidence indicates that in freeze-all cycles the cumulative live birth rate increases as the number of oocytes retrieved increases. Although the risk of severe ovarian hyperstimulation syndrome (OHSS) is virtually eliminated in freeze-all cycles, there are certain risks associated with retrieval of large oocyte cohorts. Therefore, ovarian stimulation should be planned to yield between 15 and 20 oocytes. The early follicular phase is currently the preferred starting point for ovarian stimulation, although luteal phase stimulation can be used if necessary. The improved safety associated with the GnRH antagonist regimen makes it the regimen of choice for ovarian stimulation in freeze-all cycles. Ovulation triggering with a GnRH agonist almost completely eliminates the risk of OHSS without affecting oocyte and embryo quality and is therefore the trigger of choice. The addition of low-dose hCG in a dual trigger has been suggested to improve oocyte and embryo quality, but further research in freeze-all cycles is required. Moderate-quality evidence indicates that in freeze-all cycles, a moderate delay of 2–3 days in ovulation triggering may result in the retrieval of an increased number of mature oocytes without impairing the pregnancy rate. There are no high-quality studies evaluating the effects of sustained supraphysiological estradiol (E2) levels on the safety and efficacy of freeze-all cycles. However, no significant adverse effects have been described. There is conflicting evidence regarding the effect of late follicular progesterone elevation in freeze-all cycles.
WIDER IMPLICATIONS
Ovarian stimulation for freeze-all cycles is different in many aspects from conventional stimulation for fresh IVF cycles. Optimisation of ovarian stimulation for freeze-all cycles should result in enhanced treatment safety along with improved cumulative live birth rates and should become the focus of future studies.
Collapse
Affiliation(s)
- Yossi Mizrachi
- IVF Unit, Department of Obstetrics & Gynecology, the Edith Wolfson Medical Center, Holon, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Eran Horowitz
- IVF Unit, Department of Obstetrics & Gynecology, the Edith Wolfson Medical Center, Holon, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Jacob Farhi
- IVF Unit, Department of Obstetrics & Gynecology, the Edith Wolfson Medical Center, Holon, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Arieh Raziel
- IVF Unit, Department of Obstetrics & Gynecology, the Edith Wolfson Medical Center, Holon, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ariel Weissman
- IVF Unit, Department of Obstetrics & Gynecology, the Edith Wolfson Medical Center, Holon, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| |
Collapse
|
18
|
Yılmaz N, Ceran MU, Ugurlu EN, Gülerman HC, Engin Ustun Y. GnRH agonist versus HCG triggering in different IVF/ICSI cycles of same patients: a retrospective study. J OBSTET GYNAECOL 2019; 40:837-842. [PMID: 31791167 DOI: 10.1080/01443615.2019.1674262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The aim of this study was to assess Gonadotropin Releasing Hormone agonist (GnRHa) trigger results of fresh in vitro fertilisation (IVF), Intracytoplasmic Sperm Injection (ICSI) cycles in high-responder patients. Thirty-six high-responder patients, undergoing GnRH antagonist protocol combined with GnRHa trigger for final oocyte maturation, were included. All cycles were autologous fresh transfer cycles. Fifteen of 36 patients had previous IVF/ICSI cycles triggered with human chorionic gonadotropin (hCG) and both cycles of these patients were compared. The mean fertilisation rate, blastocyst development and clinical pregnancy rates were 67%, 44.4% and 44.4%, respectively. The hCG and GnRHa trigger cycles of the same patients were compared as two groups (n: 15). 2PN oocyte counts were significantly higher in agonist trigger cycles (p .048). There were no differences in terms of M2 oocyte count and fertilisation rate. The blastocyst formation and clinical pregnancy rates for hCG and GnRHa trigger cycles were 33.3-66.7% and 13.3-46.7%, respectively. These results were found to be 2-fold and 3.5-fold higher, but not statistically significant. GnRHa trigger in combination with LPS is a good option for final oocyte maturation due to its good pregnancy outcomes and virtually eliminating OHSS risks.IMPACT STATEMENTWhat is already known on this subject? Gonadotrophin releasing hormone agonist (GnRHa) trigger is effective in the induction of oocyte maturation and prevention of Ovarian Hyperstimulation Syndrome (OHSS) on IVF cycles using antagonist protocol.What do the results of this study add? The main strength of this study is the comparison of different triggers in different cycles of the same patients. GnRHa trigger in combination with Luteal Phase Support (LPS) is a good option for final oocyte maturation due to its good pregnancy outcomes and virtually eliminating OHSS risks.What are the implications of these findings for clinical practice and/or further research? We suppose that GnRHa trigger combined with modified LPS is clinically more successful than Human Chorionic Gonadotropin (hCG) in regard to OHSS prevention and reproductive outcomes on fresh IVF/ICSI cycles. More extensive studies are needed to draw firm conclusions.
Collapse
Affiliation(s)
- Nafiye Yılmaz
- Department of Reproductive Endocrinology, Health Science University Zekai Tahir Burak Women's Health, Education and Research Hospital, Ankara, Turkey
| | - Mehmet Ufuk Ceran
- Department of Gynecology and Obstetrics, Baskent University School of Medicine, Konya Medical and Research Center, Ankara, Turkey
| | - Evin Nil Ugurlu
- Department of Gynecology and Obstetrics, Medical Park Health Group, Mersin, Turkey
| | - Hacer Cavidan Gülerman
- Department of Reproductive Endocrinology, Health Science University Zekai Tahir Burak Women's Health, Education and Research Hospital, Ankara, Turkey
| | - Yaprak Engin Ustun
- Department of Reproductive Endocrinology, Health Science University Zekai Tahir Burak Women's Health, Education and Research Hospital, Ankara, Turkey
| |
Collapse
|
19
|
Jones BP, Al-Chami A, Gonzalez X, Arshad F, Green J, Bracewell-Milnes T, Saso S, Smith R, Serhal P, Ben Nagi J. Is oocyte maturity influenced by ovulation trigger type in oocyte donation cycles? HUM FERTIL 2019; 24:360-366. [PMID: 31571498 DOI: 10.1080/14647273.2019.1671614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The aim of this study was to compare clinical and laboratory outcomes between GnRHa, dual and HCG triggers in altruistic oocyte donation cycles. Normal or high responders were given either gonadotropin releasing hormone agonist (GnRHa) or a dual trigger of GnRHa and a low dose of human chorionic gonadotropin (HCG). Low responders were given HCG trigger. In 333 cycles, 232 (69.7%) received GnRHa trigger, 59 (17.7%) received dual trigger and 42 (12.6%) had HCG trigger. The total number of mature oocytes retrieved and cryopreserved were significantly higher in the GnRHa and dual trigger groups, compared to the HCG group (p < 0.001). However, the ovarian hyperstimulation syndrome (OHSS) rate was significantly higher in the dual trigger group (n = 5 (8.5%)), compared to the GnRH agonist (n = 1 (0.4%)) and HCG groups (n = 0 (0%)) (p = 0.001). GnRHa trigger maximises mature oocyte yields in oocyte donors suspected of normal and high response but offers a significant reduction in OHSS risk compared to dual trigger. As such, dual trigger should not be used in oocyte donation. HCG trigger can also be used with a very low risk of OHSS at low risk of OHSS in carefully selected donors where GnRHa is unlikely to be effective.
Collapse
Affiliation(s)
- Benjamin P Jones
- Department of Gynaecology, Hammersmith Hospital, Imperial College NHS Trust , London , UK.,Department of Surgery and Cancer, Imperial College London , London , UK
| | - Ali Al-Chami
- Centre for Reproductive and Genetic Health , London , UK
| | | | - Falak Arshad
- Centre for Reproductive and Genetic Health , London , UK
| | - Joy Green
- Centre for Reproductive and Genetic Health , London , UK
| | | | - Srdjan Saso
- Department of Gynaecology, Hammersmith Hospital, Imperial College NHS Trust , London , UK.,Department of Surgery and Cancer, Imperial College London , London , UK
| | - Richard Smith
- Department of Gynaecology, Hammersmith Hospital, Imperial College NHS Trust , London , UK.,Department of Surgery and Cancer, Imperial College London , London , UK
| | - Paul Serhal
- Centre for Reproductive and Genetic Health , London , UK
| | - Jara Ben Nagi
- Centre for Reproductive and Genetic Health , London , UK
| |
Collapse
|
20
|
Hatırnaz Ş, Tan SL, Hatırnaz E, Çelik Ö, Kanat-Pektaş M, Dahan MH. Vaginal ultrasound-guided ovarian needle puncture compared to laparoscopic ovarian drilling in women with polycystic ovary syndrome. Arch Gynecol Obstet 2019; 299:1475-1480. [PMID: 30729291 DOI: 10.1007/s00404-019-05067-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 01/25/2019] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE To compare pregnancy outcomes in PCOS women undergoing transvaginal ovarian injury (TVOI) and laparoscopic ovarian drilling (LOD) DESIGN: 126 infertile patients with PCOS were included in this prospective cohort study CANADIAN TASK FORCE CLASSIFICATION OF LEVEL OF EVIDENCE: IIA. SETTING University-affiliated fertility center. PATIENTS Sixty-seven infertile patients with the history of failed in vitro maturation underwent follow-up as the TVOI group. Fifty-nine infertile women who underwent LOD acted as controls. All subjects had PCOS with menstrual irregularity and were anovulatory by repetitive serum progesterone levels. INTERVENTIONS The LOD group underwent six cauterizations of a single ovary with 30W for 4-6 s. Failed IVM subjects with 20-30 needle punctures per ovary acted as the TVOI group. Subjects were followed for six months. MEASUREMENTS AND MAIN RESULTS There was not a significant difference between the groups when the cases were evaluated in terms of spontaneous pregnancy or miscarriage rates. BMI levels decreased in both the TVOI and the LOD groups in a similar fashion. However, serum AMH and AFC decreased greater after LOD than they did with TVOI over the six-month duration of the study (p < 0.001 in both cases). CONCLUSIONS Preliminary data suggest that TVOI likely represents a safer, less costly and equally effective manner of surgical ovulation induction in anovulatory PCOS women when compared to LOD.
Collapse
Affiliation(s)
- Şafak Hatırnaz
- Medicana International Hospital, Yeni mahalle, Şehit Mesut Birinci Cad., No 85 Canik, Samsun, 55080, Turkey.
| | - Seang Lin Tan
- Mc Gill Fertility Center, Department of Obstetrics and Gynecology, McGill University, Montreal, Canada
| | - Ebru Hatırnaz
- Medicana International Hospital, Yeni mahalle, Şehit Mesut Birinci Cad., No 85 Canik, Samsun, 55080, Turkey
| | - Önder Çelik
- Obstetrics and Gynecology, Private Office, Uşak, Turkey
| | - Mine Kanat-Pektaş
- Department of Obstetrics and Gynecology, School of Medicine, Kocatepe University, Afyon, Turkey
| | - Michael H Dahan
- Mc Gill Fertility Center, Department of Obstetrics and Gynecology, McGill University, Montreal, Canada
| |
Collapse
|
21
|
Santos-Ribeiro S, Mackens S, Racca A, Blockeel C. Towards complication-free assisted reproduction technology. Best Pract Res Clin Endocrinol Metab 2019; 33:9-19. [PMID: 30473208 DOI: 10.1016/j.beem.2018.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Assisted reproductive technology (ART) has vastly improved over the last 40 years, from a frequently unsuccessful and complicated procedure requiring hospital admission and routine laparoscopy to a fairly simple outpatient technique with relatively high success rates. However, it is important to stress that ART is not without risk and medical complications may still occur. The incidence of most of these ART-related complications is associated with how women undergo ovarian stimulation. For this reason, physicians should be aware that a carefully thought-out ovarian stimulation protocol and cycle monitoring are of paramount importance to maximise the success of the treatment while avoiding potentially life-threating complications to occur in this frequently otherwise healthy patient population. This review discusses the rationale and evolution of ovarian stimulation strategies over the years and the current developments towards finding a balance between the retrieval of a sufficient number of oocytes and ART-related complication prevention.
Collapse
Affiliation(s)
| | - Shari Mackens
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, Brussels 1090, Belgium.
| | - Annalisa Racca
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, Brussels 1090, Belgium; Academic Unit of Obstetrics and Gynaecology, IRCCS AOU San Martino-IST, University of Genoa, Largo Rosanna Benzi 10, Genova 16132, Italy.
| | - Christophe Blockeel
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, Brussels 1090, Belgium; Department of Obstetrics and Gynaecology, School of Medicine, University of Zagreb, Šalata 3, Zagreb 10000, Croatia.
| |
Collapse
|
22
|
Comparison of GnRH agonist and hCG for priming in vitro maturation cycles in cancer patients undergoing urgent fertility preservation. PLoS One 2018; 13:e0208576. [PMID: 30521621 PMCID: PMC6283534 DOI: 10.1371/journal.pone.0208576] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 11/20/2018] [Indexed: 11/20/2022] Open
Abstract
In vitro maturation (IVM) of oocytes retrieved at germinal vesicle or Metaphase I stage, followed by vitrification of Metaphase II (MII) oocytes, has recently emerged as an option for urgent fertility preservation (FP). Priming is usually achieved with an injection of hCG, 10,000 IU, 36 hours before retrieval. This study aimed to assess a new method of priming, using GnRH agonists, and compare it to hCG, in cancer patients undergoing urgent FP. From 2009 to 2015, 373 cancer patients underwent MII oocyte cryopreservation after IVM cycles primed either with GnRHa (triptorelin 0.2 mg) (n = 138) or hCG (10,000 IU) (n = 235). Patients’ characteristics were comparable between the two groups. The number of COC retrieved was significantly higher in the GnRHa group (9.1 ± 6.8 versus 7.7 ± 5.5 oocytes, p = 0.04). However, the maturation rates (59 ±25% versus 64 ±26%, p = 0.07, respectively), and the total number of MII oocytes frozen (5.2 ±4.2 versus 4.9 ±4.0, p = 0.6, respectively) were similar between the GnRha and hCG groups. We did not find any difference between GnRHa and hCG priming for IVM. GnRHa priming is more physiological since it stimulates endogenous FSH and LH activity, and is well suited for FP in hormone-sensitive cancers and urgent cases.
Collapse
|
23
|
Ammar IMM, Alnemr AAA, Abdou AM, Shazly SA. Gonadotropin-releasing hormone agonist versus human chorionic gonadotropin for ovulation triggering in letrozole stimulated cycles. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2018. [DOI: 10.1016/j.mefs.2018.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
|
24
|
|
25
|
Benadiva C, Engmann L. Luteal phase support after gonadotropin-releasing hormone agonist triggering: does it still matter? Fertil Steril 2018; 109:763-767. [DOI: 10.1016/j.fertnstert.2018.02.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 01/26/2018] [Accepted: 02/01/2018] [Indexed: 12/17/2022]
|
26
|
Zander-Fox D, Lane M, Hamilton H, Tremellen K. Sequential clomiphene/corifollitrophin alpha as a technique for mild controlled ovarian hyperstimulation in IVF: a proof of concept study. J Assist Reprod Genet 2018; 35:1047-1052. [PMID: 29633146 DOI: 10.1007/s10815-018-1172-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 03/23/2018] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Mild controlled ovarian hyperstimulation (COH), combined with oocyte retrieval (OR) under local anaesthesia (LA), may provide low-impact IVF. Since a single injection of corifollitrophin alfa (CFA) provides 7 days of COH, we hypothesised that clomiphene-citrate (CC) followed by CFA may provide adequate COH response from one single FSH injection. Therefore, the aim was to assess IVF outcomes after a novel clomiphene citrate/CFA (CC/CFA) protocol, compared to women undergoing standard rFSH COH protocols (good prognosis comparative cohort:GPCC) in a 1:2 matched design. MATERIALS AND METHODS In this pilot study of 25 patients (ANZCTR id:ACTRN12612000740897, MINIVA:Minimal_Stimulation_in_IVF), we examined the effectiveness of oral clomiphene (100 mg-days 2-6) followed by CFA in a GnRH antagonist protocol producing a single injection COH stimulation regime. All OR were conducted under LA pre-ovarian block. Cycle outcomes were compared to a matched good prognosis comparative cohort (GPCC) undergoing standard rFSH COH. RESULTS Mild stimulation was achieved with less oocytes being collected compared to the GPCC (6.4 ± 0.7 vs. 10.7 ± 0.9, p < 0.001), resulting in a reduced number of good quality embryos available for transfer/cryopreservation (3.7 ± 0.6 vs. 5.7 ± 0.5, p = 0.01). While embryo quality was similar between the two groups, endometrial thickness was significantly lower in the group receiving CC/CFA. Pregnancy rates were significantly lower in the CC/CFA cohort compared to GPCC (31.8 vs. 57.1%, p = 0.04) and 44% of CC/CFA participants required supplemental rFSH in order to achieve the hCG trigger criteria. CONCLUSION Sequential clomiphene CFA protocol does not appear to be an optimal regime for low impact IVF treatment as it does not provide adequate COH from a single CFA injection and results in lower fresh embryo transfer pregnancy rates and fewer embryos for cryopreservation.
Collapse
Affiliation(s)
- Deirdre Zander-Fox
- Repromed, 180 Fullarton Road, Dulwich, 5065, South Australia. .,MonashIVF Group, 21-31 Goodwood Street, Richmond, Victoria, 3121, Australia. .,Department of Obstetrics and Gynaecology, Medical School North, University of Adelaide, Frome Rd, Adelaide, 5000, Australia.
| | - Michelle Lane
- Repromed, 180 Fullarton Road, Dulwich, 5065, South Australia.,MonashIVF Group, 21-31 Goodwood Street, Richmond, Victoria, 3121, Australia.,Department of Obstetrics and Gynaecology, Medical School North, University of Adelaide, Frome Rd, Adelaide, 5000, Australia
| | - Hamish Hamilton
- Repromed, 180 Fullarton Road, Dulwich, 5065, South Australia.,MonashIVF Group, 21-31 Goodwood Street, Richmond, Victoria, 3121, Australia
| | - Kelton Tremellen
- Repromed, 180 Fullarton Road, Dulwich, 5065, South Australia.,Department of Obstetrics Gynaecology and Reproductive Medicine, Flinders Medical Centre, Flinders University, Flinders Drive, Bedford Park, 5042, South Australia
| |
Collapse
|
27
|
Karacan M, Erdem E, Usta A, Arvas A, Cebi Z, Camlibel T. Gonadotropin-releasing hormone agonist triggering with concomitant administration of low doses of human chorionic gonadotropin or a freeze-all strategy in high responders. Saudi Med J 2018; 38:586-591. [PMID: 28578436 PMCID: PMC5541180 DOI: 10.15537/smj.2017.6.17717] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives: To compare the live birth rates and moderate/severe ovarian hyperstimulation syndrome (OHSS) rates of 2 different approaches using gonadotropin-releasing hormone (GnRH) agonist triggering in high responder women. Methods: A retrospective cohort study was performed to evaluate intracytoplasmic sperm injection (ICSI) and embryo transfer (ET) outcomes in high responder women who underwent ovulation induction with a GnRH antagonist protocol between April 2011 and March 2015. In group 1 (n=74), GnRH agonist was used for ovulation triggering with the concomitant use of 1500 IU of urinary human chorionic gonadotropin (hCG) immediately after oocyte retrieval followed by fresh ET and standard luteal support. In group 2 (n=48), GnRH agonist was used for triggering after freezing all embryos and subsequent frozen/thawed embryo transfer (FET); this approach is considered the “freeze-all” approach. Results: Baseline characteristics were similar between the groups. The clinical pregnancy rates for group 1 was 45.9% and group 2 was 43.8% (p=0.812, chi-squared test) and live birth rates for group 1 was 40.5% and for group 2 41.7% (p=0.902, chi-squared test) were comparable between groups. In group 1, late-onset OHSS was observed (one severe case and one moderate case) in 2 patients (2.7%). In group 2, none of the patients experienced moderate/severe OHSS. Conclusion: The live birth rate with GnRH agonist triggering and concomitant use of 1500 IU of hCG immediately after oocyte retrieval was similar to that obtained with the freeze-all approach and FET in a subsequent cycle. The administration of a low dose of hCG in GnRH agonist trigger cycles caused moderate/severe OHSS in 2.7% of the patients.
Collapse
Affiliation(s)
- Meric Karacan
- Department of Assisted Reproduction Unit, Ota-Jinemed Hospital, Besiktas, Istanbul, Turkey. E-mail.
| | | | | | | | | | | |
Collapse
|
28
|
Gonadotropin-Releasing Hormone–Agonist Triggering and a Freeze-All Approach: The Final Step in Eliminating Ovarian Hyperstimulation Syndrome? Obstet Gynecol Surv 2017; 72:296-308. [DOI: 10.1097/ogx.0000000000000432] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
|
29
|
Vlaisavljević V, Kovačič B, Knez J. Cumulative live birth rate after GnRH agonist trigger and elective cryopreservation of all embryos in high responders. Reprod Biomed Online 2017; 35:42-48. [PMID: 28416291 DOI: 10.1016/j.rbmo.2017.03.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 03/21/2017] [Accepted: 03/22/2017] [Indexed: 12/14/2022]
Abstract
Elective embryo cryopreservation after using gonadotrophin-releasing hormone (GnRH) antagonist protocols and GnRH agonist triggering is becoming an increasingly important part of medically assisted reproduction. We designed a single-centre retrospective study to assess the cumulative probability of achieving a live birth through consecutive transfers of vitrified-warmed blastocysts after elective embryo cryopreservation in high-responding patients. Hence, 123 women identified to be at high risk for developing ovarian hyperstimulation syndrome were included. They were stimulated using GnRH antagonist protocol, and GnRH agonist was used to trigger final oocyte maturation. All embryos were vitrified at the blastocyst stage and transferred in the subsequent menstrual cycles. Using the Kaplan-Meier survival analysis, a total of 65.9% (95% CI 57.5 to 74.3) women achieved a live birth after a maximum of six embryo transfer cycles using the 'conservative' approach. Applying the 'optimistic' approach, presuming that women who still had cryopreserved embryos and did not return for embryo transfer had the same chance of achieving a live birth as those returning for transfer, the cumulative live birth rate estimated in six embryo transfer cycles was 76.6% (95% CI 69.1 to 84.1). No cases of severe ovarian hyperstimulation syndrome were recorded.
Collapse
Affiliation(s)
- Veljko Vlaisavljević
- Department of Reproductive Medicine and Gynaecologic Endocrinology, University Medical Centre Maribor, 2000 Maribor, Slovenia; Biomedical Research Insitute (BRIS), 1000 Ljubljana, Slovenia
| | - Borut Kovačič
- Department of Reproductive Medicine and Gynaecologic Endocrinology, University Medical Centre Maribor, 2000 Maribor, Slovenia
| | - Jure Knez
- Department of Reproductive Medicine and Gynaecologic Endocrinology, University Medical Centre Maribor, 2000 Maribor, Slovenia.
| |
Collapse
|
30
|
Dosouto C, Haahr T, Humaidan P. Gonadotropin-releasing hormone agonist (GnRHa) trigger – State of the art. Reprod Biol 2017; 17:1-8. [DOI: 10.1016/j.repbio.2017.01.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/04/2017] [Accepted: 01/05/2017] [Indexed: 02/07/2023]
|
31
|
|
32
|
Abstract
This review attempts to summarize the known literature on high responders to ovarian stimulation during assisted reproductive techniques (ART). Response to gonadotrophins is subject to significant interindividual and intercycle variation, thus carrying a risk of high response or poor response to ovarian stimulation regimens. The main risk for high responders is the development of ovarian hyperstimulation syndrome (OHSS) which is associated with significant morbidity. Hence, the definition of high responders in the literature has primarily focussed on risk factors for OHSS. Strategies to reduce OHSS including tailoring of the ovarian stimulation regimens and adjusting gonadotrophin doses according to patient characteristics and findings during the cycle of stimulation. In addition, modifying the type of ovulation trigger used and adjuvant therapies, such as metformin, intravenous colloids and vascular endothelial growth factor blockers, have also been studied as options to reduce OHSS. Apart from the risk of OHSS, high response also appears to have an adverse impact on the oocyte and endometrium, though there is a paucity of data regarding the extent and mechanisms behind this impact.
Collapse
Affiliation(s)
- Mariano Mascarenhas
- a Seacroft Hospital , Leeds Centre for Reproductive Medicine , Leeds , United Kingdom
| | - Adam H Balen
- a Seacroft Hospital , Leeds Centre for Reproductive Medicine , Leeds , United Kingdom
| |
Collapse
|
33
|
Haahr T, Roque M, Esteves SC, Humaidan P. GnRH Agonist Trigger and LH Activity Luteal Phase Support versus hCG Trigger and Conventional Luteal Phase Support in Fresh Embryo Transfer IVF/ICSI Cycles-A Systematic PRISMA Review and Meta-analysis. Front Endocrinol (Lausanne) 2017; 8:116. [PMID: 28638367 PMCID: PMC5461358 DOI: 10.3389/fendo.2017.00116] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The use of GnRH agonist (GnRHa) for final oocyte maturation trigger in oocyte donation and elective frozen embryo transfer cycles is well established due to lower ovarian hyperstimulation syndrome (OHSS) rates as compared to hCG trigger. A recent Cochrane meta-analysis concluded that GnRHa trigger was associated with reduced live birth rates (LBRs) in fresh autologous IVF cycles compared to hCG trigger. However, the evidence is not unequivocal, and recent trials have found encouraging reproductive outcomes among couples undergoing GnRHa trigger and individualized luteal LH activity support. Thus, the aim was to compare GnRHa trigger followed by luteal LH activity support with hCG trigger in IVF patients undergoing fresh embryo transfer. MATERIAL AND METHODS We conducted a systematic review and meta-analysis of randomized trials published until December 14, 2016. The population was infertile patients submitted to IVF/ICSI cycles with GnRH antagonist cotreatment who underwent fresh embryo transfer. The intervention was GnRHa trigger followed by LH activity luteal phase support (LPS). The comparator was hCG trigger followed by a standard LPS. The critical outcome measures were LBR and OHSS rate. The secondary outcome measures were number of oocytes retrieved, clinical and ongoing pregnancy rates, and miscarriage rates. RESULTS A total of five studies met the selection criteria comprising a total of 859 patients. The LBR was not significantly different between the GnRHa and hCG trigger groups (OR 0.84, 95% CI 0.62, 1.14). OHSS was reported in a total of 4/413 cases in the GnRHa group compared to 7/413 in the hCG group (OR 0.48, 95% CI 0.15, 1.60). We observed a slight, but non-significant increase in miscarriage rate in the GnRHa triggered group compared to the hCG group (OR 1.85; 95% CI 0.97, 3.54). CONCLUSION GnRHa trigger with LH activity LPS resulted in comparable LBRs compared to hCG trigger. The most recent trials reported LBRs close to unity indicating that individualization of the LH activity LPS improved the luteal phase deficiency reported in the first GnRHa trigger studies. However, LPS optimization is needed to further limit OHSS in the subgroup of normoresponder patients (<14 follicles ≥ 11 mm). PROSPERO REGISTRATION NUMBER CRD42016051091.
Collapse
Affiliation(s)
- Thor Haahr
- The Fertility Clinic Skive Regional Hospital, Skive, Denmark
- Faculty of Health, Aarhus University, Aarhus C, Denmark
- *Correspondence: Thor Haahr,
| | - Matheus Roque
- ORIGEN – Center for Reproductive Medicine, Rio de Janeiro, Brazil
| | - Sandro C. Esteves
- Faculty of Health, Aarhus University, Aarhus C, Denmark
- ANDROFERT, Andrology and Human Reproduction Clinic, São Paulo, Brazil
- Department of Surgery, University of Campinas (UNICAMP), São Paulo, Brazil
| | - Peter Humaidan
- The Fertility Clinic Skive Regional Hospital, Skive, Denmark
- Faculty of Health, Aarhus University, Aarhus C, Denmark
| |
Collapse
|
34
|
Messini CI, Daponte A, Anifandis G, Mahmood T, Messinis IE. Standards of Care in infertility in Europe. Eur J Obstet Gynecol Reprod Biol 2016; 207:S0301-2115(16)30951-4. [PMID: 28029396 DOI: 10.1016/j.ejogrb.2016.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 10/14/2016] [Indexed: 11/25/2022]
Abstract
Evidence-based medicine is the principal approach to medical practice. There are several debatable issues in infertility, which require clarification. Over the past 20 years, reliable methodology has been developed for the management of infertile couples. This includes high quality diagnostic and therapeutic procedures, which are applied in highly specialised infertility centres. The European Board and College of Obstetrics and Gynaecology (EBCOG) has published Standards of Care for Women's Health in Europe, which should be the cornerstone for the clinicians and service providers in the European Union to establish common protocols within their centres. Each infertility treatment should result in the highest possible success rate and all appropriate measures for the patient's safety should be in place. The treatment protocols should minimise risk of complications, such as ovarian hyperstimulation syndrome (OHSS). The current use of GnRH agonists to trigger final follicle maturation has provided the means for avoiding this syndrome. Additionally, multiple pregnancy rates are still high in assisted reproductive technology (ART). These rates should be reduced by the adoption of single embryo transfer during IVF treatment and by the proper monitoring of ovulation induction protocols. EBCOG Standards of Care for infertility and assisted conception treatment derived from the best available evidence should underpin the provision of high quality infertility services in European countries.
Collapse
Affiliation(s)
- Christina I Messini
- Department of Obstetrics & Gynaecology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Alexandros Daponte
- Department of Obstetrics & Gynaecology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Anifandis
- Department of Obstetrics & Gynaecology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Tahir Mahmood
- Department of Obstetrics & Gynaecology, Victoria Hospital, Kirkcaldy, Scotland, UK; European Board and College of Obstetrics & Gynaecology (EBCOG), UK
| | - Ioannis E Messinis
- Department of Obstetrics & Gynaecology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; European Board and College of Obstetrics & Gynaecology (EBCOG), UK.
| |
Collapse
|
35
|
Chang FE, Beall SA, Cox JM, Richter KS, DeCherney AH, Levy MJ. Assessing the adequacy of gonadotropin-releasing hormone agonist leuprolide to trigger oocyte maturation and management of inadequate response. Fertil Steril 2016; 106:1093-1100.e3. [DOI: 10.1016/j.fertnstert.2016.06.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Revised: 05/22/2016] [Accepted: 06/06/2016] [Indexed: 10/21/2022]
|
36
|
Christopoulos G, Vlismas A, Carby A, Lavery S, Trew G. GnRH agonist trigger with intensive luteal phase support vs. human chorionic gonadotropin trigger in high responders: an observational study reporting pregnancy outcomes and incidence of ovarian hyperstimulation syndrome. HUM FERTIL 2016; 19:199-206. [PMID: 27662416 DOI: 10.1080/14647273.2016.1217432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
A retrospective, cohort study of high-risk patients undergoing IVF treatment was performed to assess if there is a difference in clinical pregnancy rate, live birth rate and the incidence of ovarian hyperstimulation syndrome, when a GnRH agonist (GnRHa) trigger with intensive luteal support is compared to human chorionic gonadotropin (hCG) with standard luteal support. The control group consisted of 382 high-risk patients having a GnRH antagonist protocol with 194 receiving an hCG trigger. All patients had ≥18 follicles ≥11mm or serum oestradiol >18,000pmol/l on the day of trigger. Patients had a single or double embryo transfer at cleavage or blastocyst stage. Logistic regression was used to adjust for differences between the groups. An intention-to-treat analysis of all cycles was performed. No statistically significant differences were observed in terms of positive pregnancy test, clinical pregnancy rate and live birth rate. Only one patient (0.3%) was hospitalized with severe OHSS in the GnRHa group, compared to 26 patients (13%) in the hCG group. In conclusion, GnRHa trigger is associated with similar pregnancy rates with hCG trigger and a significant reduction in hospitalization for severe OHSS after an intention to treat analysis was performed.
Collapse
Affiliation(s)
| | | | | | - Stuart Lavery
- a IVF Unit , Hammersmith Hospital , London , UK ;,b Boston Place Clinic , London , UK
| | - Geoffrey Trew
- a IVF Unit , Hammersmith Hospital , London , UK ;,b Boston Place Clinic , London , UK
| |
Collapse
|
37
|
Santos-Ribeiro S, Polyzos NP, Lan VTN, Siffain J, Mackens S, Van Landuyt L, Tournaye H, Blockeel C. The effect of an immediate frozen embryo transfer following a freeze-all protocol: a retrospective analysis from two centres. Hum Reprod 2016; 31:2541-2548. [DOI: 10.1093/humrep/dew194] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 05/24/2016] [Accepted: 07/13/2016] [Indexed: 11/14/2022] Open
|
38
|
Alyasin A, Mehdinejadiani S, Ghasemi M. GnRH agonist trigger versus hCG trigger in GnRH antagonist in IVF/ICSI cycles: A review article. Int J Reprod Biomed 2016. [DOI: 10.29252/ijrm.14.9.557] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
|
39
|
El Tokhy O, Kopeika J, El-Toukhy T. An update on the prevention of ovarian hyperstimulation syndrome. ACTA ACUST UNITED AC 2016; 12:496-503. [PMID: 27543490 DOI: 10.1177/1745505716664743] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 07/17/2016] [Accepted: 07/22/2016] [Indexed: 11/17/2022]
Abstract
Ovarian hyperstimulation syndrome is a potentially life-threatening, but preventable iatrogenic complication of in vitro fertilisation treatment. In recent years, new strategies have been developed to minimise the risk of ovarian hyperstimulation syndrome after in vitro fertilisation, including better at-risk patient identification prior to starting treatment, the use of a lower human chorionic gonadotrophin dose or alternative medication instead of human chorionic gonadotrophin to induce final oocyte maturation such as gonadotrophin-releasing hormone agonist and kisspeptin in antagonist cycles, cryopreservation of all embryos and delayed embryo transfer, and the use of oral dopamine agonists after oocyte retrieval. In this article, the advantages and limitations of those new developments are discussed and future directions towards establishment of an ovarian hyperstimulation syndrome-free in vitro fertilisation clinic are explored.
Collapse
Affiliation(s)
- Omar El Tokhy
- Faculty of Medicine, Imperial College London, London, UK
| | - Julia Kopeika
- Assisted Conception Unit, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Tarek El-Toukhy
- Assisted Conception Unit, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| |
Collapse
|
40
|
[Is gonadotropin releasing hormone (GnRH) agonist trigger beneficial or deleterious?]. ACTA ACUST UNITED AC 2016; 44:403-9. [PMID: 27451069 DOI: 10.1016/j.gyobfe.2016.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 05/26/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The undeniable asset of the antagonist protocols in in vitro fertilization is the decrease of the risks of ovarian hyperstimulation syndrome, by the use of a release by GnRH agonist. Nevertheless, questioning persist concerning the rates of clinical pregnancies, the oocyte quantity and the empty follicle syndrome. We thus studied these parameters in our center. METHODS A retrospective study was realized from January 1st, 2013 till July 31st, 2015. The main objective was the evaluation of the rate of clinical pregnancies in antagonist protocol. A first group of 775 cycles have benefited from a release of the ovulation by HCG, while a second group of 204 cycles, by GnRH agonist. The secondary objectives were the oocyte quantity, the rate of ovarian hyperstimulation syndrome, and the rate of empty follicle syndrome. RESULTS No statistically significant difference was found between both groups concerning the rates of clinical pregnancies, oocytes quantity, and the rate of empty follicle syndrome, whatever is the type of used release, in fresh embryo transfer. A syndrome of premature ovarian hyperstimulation syndrome was found at 7.9 % of the patients in the group 2 versus 2.3 % in the group 1, with a statistically significant difference (P<0.05). At these patients, a strategy of frozen embryo transfer ("freeze all") was proposed. The accumulated rates by pregnancy in both groups were not statistically different. CONCLUSION The release by GnRH agonist does not show inferiority in terms of clinical pregnancy, in comparison to HCG.
Collapse
|
41
|
GnRH agonist with low-dose hCG (dual trigger) is associated with higher risk of severe ovarian hyperstimulation syndrome compared to GnRH agonist alone. J Assist Reprod Genet 2016; 33:1175-84. [PMID: 27349252 DOI: 10.1007/s10815-016-0755-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 06/06/2016] [Indexed: 10/21/2022] Open
Abstract
PURPOSE The purpose of this study was to compare rates of ovarian hyperstimulation syndrome (OHSS) after using gonadotropin-releasing hormone agonists (GnRHa) alone and GnRHa in combination with low-dose human chorionic gonadotropin (hCG, dual trigger) for final oocyte maturation in women undergoing controlled ovarian hyperstimulation (COH). METHODS A retrospective cohort study was conducted at an academic center. Study population included 108 women who received GnRHa trigger and 66 women who received dual trigger (GnRHa + low-dose [1000 IU] hCG trigger). The main outcome measure was OHSS. Secondary outcomes included total oocyte yield and oocyte maturity. RESULTS The incidence of early OHSS was significantly higher after dual trigger than GnRHa trigger (8.6 vs 0 %). Moreover, four of the six patients that developed OHSS developed severe OHSS. Logistic modeling revealed that the combination of age, BMI, baseline AFC, and E2 >4000 pg/mL was predictive of OHSS with an area under the receiver operating characteristic curve of 0.84 and was superior to each factor alone. Adjusted analyses revealed that dual trigger was associated with a higher number of total oocytes (adjusted OR 1.27; 95 % confidence interval, 1.18, 1.38) and percentage of mature oocytes (AOR 1.10; 95 % confidence interval, 1.03, 1.17) obtained compared to GnRHa trigger alone. CONCLUSIONS Dual trigger for final oocyte maturation using GnRHa and low-dose hCG is associated with a significantly increased risk of severe OHSS compared to GnRH alone. However, dual trigger may be associated with a modest increase in oocyte yield, both in terms of number and maturity.
Collapse
|
42
|
Gurbuz AS, Deveer R, Kucuk M, Ozcimen N, Incesu D, Koseoglu S. Is It Possible to Prevent Ovarian Hyperstimulation Syndrome by Gonadotropin-Releasing Hormone Agonist Triggering and Modified Luteal Support in Patients With Polycystic Ovarian Morphology? J Clin Med Res 2016; 8:396-401. [PMID: 27081426 PMCID: PMC4817580 DOI: 10.14740/jocmr2500w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2016] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Gonadotropin-releasing hormone (GnRH) agonist triggering plus 1,500 IU human chorionic gonadotropin (hCG) supplementation protocol was previously claimed effective in reducing the ovarian hyperstimulation syndrome (OHSS) incidence in high responders. METHODS This retrospective study included women with polycystic ovarian (PCO) morphology who were at high risk of OHSS and were given the GnRH agonist trigger plus hCG luteal support protocol in a single center. RESULTS The mean peak estradiol level was 5,336 ± 2,341 (1,187 - 19,746) pg/mL. The mean number of follicles > 12 mm on the day of trigger was 22 ± 7 (9 - 51). A total of 88 cycles were undertaken. Sixty-three (71.5%) women underwent fresh embryo transfer. Fresh embryo transfer was canceled in 21 (23.8%) and embryo transfer was canceled in four (4.5%) women. The overall clinical pregnancy rate was 46.4% per started cycle. A total of 12 (13.6%) patients developed OHSS. "Freeze-all" policy did not attenuate OHSS in four patients, and three of these patients developed OHSS despite 1,500 IU hCG was not administered. CONCLUSION We conclude that OHSS may still occur with the use of a GnRH agonist trigger combined with low-dose hCG supplementation protocol in women with polycystic ovary syndrome (PCOS) or PCO morphology. Furthermore, we also conclude that "freeze-all" policy also will not completely eliminate OHSS development in high-risk women.
Collapse
Affiliation(s)
| | - Ruya Deveer
- Department of Obstetrics and Gynecology, School of Medicine, Mugla Sitki Kocman University, Mugla, Turkey
| | - Mert Kucuk
- Department of Obstetrics and Gynecology, School of Medicine, Mugla Sitki Kocman University, Mugla, Turkey
| | | | | | - Sezen Koseoglu
- Department of Obstetrics and Gynecology, School of Medicine, Mugla Sitki Kocman University, Mugla, Turkey
| |
Collapse
|
43
|
Ovarian hyperstimulation syndrome in the 21st century: the role of gonadotropin-releasing hormone agonist trigger and kisspeptin. Curr Opin Obstet Gynecol 2016; 27:210-4. [PMID: 25811256 DOI: 10.1097/gco.0000000000000170] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE OF REVIEW Ovarian hyperstimulation syndrome (OHSS) complicates a considerable part of stimulated in-vitro fertilization (IVF) cycles and is a potential iatrogenic cause of death in otherwise healthy women undergoing fertility treatment. The triggering factor of OHSS is the widespread use of human chorionic gonadotropin (hCG) to induce final oocyte maturation. The aim of this review is to summarize different approaches available, using alternative triggering protocols such as gonadotropin-releasing hormone agonist (GnRHa) or kisspeptin for final oocyte maturation. RECENT FINDINGS According to the latest European Society of Human Reproduction and Embryology report, the incidence of OHSS ranges from 0.18 to 1.40% in European countries. However, OHSS is still subject to substantial underreporting. New triggering protocols using GnRHa have shown to be similar to the gold standard hCG-trigger with regard to the reproductive outcome, but with a significant decrease in - and almost elimination of - OHSS. Lately, promising results have been reported for the use of kisspeptin to induce final oocyte maturation. Although until now no study has been performed in an OHSS risk population, theoretically, the risk of OHSS development might be even further reduced after kisspeptin trigger. SUMMARY GnRHa trigger is currently the best tool we have to prevent OHSS and at the same time maintain good reproductive outcomes. Future research will explore the safety and efficacy of kisspeptin trigger.
Collapse
|
44
|
Engmann L, Benadiva C, Humaidan P. GnRH agonist trigger for the induction of oocyte maturation in GnRH antagonist IVF cycles: a SWOT analysis. Reprod Biomed Online 2016; 32:274-85. [PMID: 26803205 DOI: 10.1016/j.rbmo.2015.12.007] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Revised: 12/19/2015] [Accepted: 12/22/2015] [Indexed: 01/26/2023]
Abstract
Gonadotrophin releasing hormone agonist (GnRHa) trigger is effective in the induction of oocyte maturation and prevention of ovarian hyperstimulation syndrome during IVF treatment. This trigger concept, however, results in early corpora lutea demise and consequently luteal phase dysfunction and impaired endometrial receptivity. The aim of this strenghths, weaknesses, opportunities and threats analysis was to summarize the progress made over the past 15 years to optimize ongoing pregnancy rates after GnRHa trigger. The advantages and potential drawbacks of this type of triggering are reviewed. The current approach to the management of GnRHa trigger in autologous cycles is based on the peak serum oestradiol level or follicle number and aims at a fresh embryo transfer or a segmentation approach with elective cryopreservation policy. We recommend intensive luteal support with transdermal oestradiol and intramuscular progesterone alone if peak serum oestradiol is 4000 or more pg/ml after GnRHa trigger or dual trigger with GnRHa and HCG 1000 IU if peak serum oestradiol is less than 4000 pg/mL. On the contrary, we recommend HCG 1500 IU 35 h after GnRHa trigger if there are less than 25 follicles, or freeze all oocytes or embryos if there are over 25 follicles.
Collapse
Affiliation(s)
- Lawrence Engmann
- Department of Obstetrics and Gynecology, Center for Advanced Reproductive Services, University of Connecticut School of Medicine, 2 Batterson Park Road, Farmington, CT, USA.
| | - Claudio Benadiva
- Department of Obstetrics and Gynecology, Center for Advanced Reproductive Services, University of Connecticut School of Medicine, 2 Batterson Park Road, Farmington, CT, USA
| | - Peter Humaidan
- The Fertility Clinic, Skive Regional Hospital and Faculty of Health, Aarhus University, Resenvej 25, 7800 Skive, Denmark
| |
Collapse
|
45
|
Farag AH, El-deen MHN, Hassan RM. Triggering ovulation with gonadotropin-releasing hormone agonist versus human chorionic gonadotropin in polycystic ovarian syndrome. A randomized trial. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2015. [DOI: 10.1016/j.mefs.2015.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
|
46
|
Palomba S, Santagni S, La Sala GB. Progesterone administration for luteal phase deficiency in human reproduction: an old or new issue? J Ovarian Res 2015; 8:77. [PMID: 26585269 PMCID: PMC4653859 DOI: 10.1186/s13048-015-0205-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 11/11/2015] [Indexed: 12/25/2022] Open
Abstract
Luteal phase deficiency (LPD) is described as a condition of insufficient progesterone exposure to maintain a regular secretory endometrium and allow for normal embryo implantation and growth. Recently, scientific focus is turning to understand the physiology of implantation, in particular the several molecular markers of endometrial competence, through the recent transcriptomic approaches and microarray technology. In spite of the wide availability of clinical and instrumental methods for assessing endometrial competence, reproducible and reliable diagnostic tests for LPD are currently lacking, so no type-IA evidence has been proposed by the main scientific societies for assessing endometrial competence in infertile couples. Nevertheless, LPD is a very common condition that may occur during a series of clinical conditions, and during controlled ovarian stimulation (COS) and hyperstimulation (COH) programs. In many cases, the correct approach to treat LPD is the identification and correction of any underlying condition while, in case of no underlying dysfunction, the treatment becomes empiric. To date, no direct data is available regarding the efficacy of luteal phase support for improving fertility in spontaneous cycles or in non-gonadotropin induced ovulatory cycles. On the contrary, in gonadotropin in vitro fertilization (IVF) and non-IVF cycles, LPD is always present and progesterone exerts a significant positive effect on reproductive outcomes. The scientific debate still remains open regarding progesterone administration protocols, specially on routes of administration, dose and timing and the potential association with other drugs, and further research is still needed.
Collapse
Affiliation(s)
- Stefano Palomba
- Centre of Reproductive Medicine and Surgery, Arcispedale Santa Maria Nuova - IRCCS, Viale Risorgimento 80, 42123, Reggio Emilia, Italy.
| | - Susanna Santagni
- Centre of Reproductive Medicine and Surgery, Arcispedale Santa Maria Nuova - IRCCS, Viale Risorgimento 80, 42123, Reggio Emilia, Italy.
| | - Giovanni Battista La Sala
- Centre of Reproductive Medicine and Surgery, Arcispedale Santa Maria Nuova - IRCCS, University of Modena and Reggio Emilia, Via Università 4, 41100 Viale Risorgimento 80, 42123, Modena, Italy.
| |
Collapse
|
47
|
Vuong TNL, Ho MT, Ha TD, Phung HT, Huynh GB, Humaidan P. Gonadotropin-releasing hormone agonist trigger in oocyte donors co-treated with a gonadotropin-releasing hormone antagonist: a dose-finding study. Fertil Steril 2015; 105:356-63. [PMID: 26523330 DOI: 10.1016/j.fertnstert.2015.10.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 10/07/2015] [Accepted: 10/13/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To determine the optimal GnRH agonist dose for triggering of oocyte maturation in oocyte donors. DESIGN Single-center, randomized, parallel, investigator-blinded trial. SETTING IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam. PATIENT(S) One hundred sixty-five oocyte donors (aged 18-35 years, body mass index [BMI] <28 kg/m(2), antimüllerian hormone level >1.25 ng/mL, and antral follicle count ≥6). INTERVENTION(S) Ovulation trigger with 0.2, 0.3, or 0.4 mg triptorelin in a GnRH antagonist cycle. MAIN OUTCOME MEASURE(S) The primary end point was number of metaphase II oocytes. Secondary end points were fertilization and cleavage rates, number of embryos and top-quality embryos, steroid levels, ovarian volume, and ongoing pregnancy rate (PR) in recipients. RESULT(S) There were no significant differences between the triptorelin 0.2, 0.3, and 0.4 mg trigger groups with respect to number of metaphase II oocytes (16.0 ± 8.5, 15.9 ± 7.8, and 14.7 ± 8.4, respectively), embryos (13.2 ± 7.8, 11.7 ± 6.9, 11.8 ± 7.0), and number of top-quality embryos (3.8 ± 2.9, 3.6 ± 3.0, 4.1 ± 3.0). Luteinizing hormone levels at 24 hours and 36 hours after trigger was significantly higher with triptorelin 0.4 mg versus 0.2 mg and 0.3 mg (9.8 ± 7.1 IU/L vs. 7.3 ± 4.1 IU/L and 7.2 ± 3.7 IU/L, respectively; 4.6 ± 3.2 IU/L vs. 3.2 ± 2.3 IU/L and 3.3 ± 2.1 IU/L, respectively. Progesterone level at oocyte pick-up +6 days was significantly higher in the 0.4-mg group (2.2 ± 3.7 ng/ml) versus 0.2 mg (1.1 ± 1.0 ng/ml) and 0.3 mg (1.2 ± 1.6 ng/ml). One patient developed early-onset severe ovarian hyperstimulation syndrome (OHSS). CONCLUSION(S) No significant differences between triptorelin doses of 0.2, 0.3, and 0.4 mg used for ovulation trigger in oocyte donors were seen with regard to the number of mature oocytes and top-quality embryos. CLINICAL TRIAL REGISTRATION NUMBER NCT02208986.
Collapse
Affiliation(s)
- Thi Ngoc Lan Vuong
- Department of Obstetrics and Gynaecology, University of Medicine and Pharmacy HCMC, Ho Chi Minh City, Vietnam; IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam.
| | - Manh Tuong Ho
- IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam; Research Center for Genetics and Reproductive Health (CGRH), School of Medicine, Vietnam National University HCMC, Ho Chi Minh City, Vietnam
| | - Tan Duc Ha
- National Hospital of Can Tho, Ho Chi Minh City, Vietnam; Ton Duc Thang University, Ho Chi Minh City, Vietnam
| | | | | | - Peter Humaidan
- The Fertility Clinic, Skive Regional Hospital, Aarhus, Denmark; Faculty of Health, Aarhus University and Faculty of Health, University of Southern Denmark, Aarhus, Denmark
| |
Collapse
|
48
|
Gat I, Shlush E, Quach K, Librach CL. The continuum of high ovarian response: a rational approach to the management of high responder patient subgroups. Syst Biol Reprod Med 2015; 61:336-44. [PMID: 26516651 DOI: 10.3109/19396368.2015.1089607] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Ovarian follicular responsiveness to controlled ovarian hyperstimulation (COH) with gonadotropins is extremely variable between individual patients, and even from cycle to cycle for the same patient. High responder patients are characterized by an exaggerated response to gonadotropin administration, accompanied by a higher risk for ovarian hyperstimulation syndrome (OHSS). In spite of its importance, the literature regarding high responders is characterized by heterogeneous classification methodologies. A clear separation should be drawn between risk factors for a high ovarian response and the actual response exhibited by a patient to stimulation. Similarly, it is important to distinguish between high ovarian response and development of clinically significant OHSS. In this article we: (1) review recent publications pertaining to the identification and clinical management of high responders, (2) propose an integrated clinical model to differentiate sub-groups within this population based on this review, and (3) suggest specific protocols for each sub-group. The model is based on a chronological patient assessment in an effort to target treatment based on the specific clinical circumstances. It is our hope that the algorithm we have developed will assist clinicians to supply targeted and precise treatments in order to achieve a favorable reproductive outcome with minimum complications for each patient.
Collapse
Affiliation(s)
- Itai Gat
- a CReATe Fertility Centre , Toronto , Ontario , Canada .,b Pinchas Borenstein Talpiot Medical Leadership Program, Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel; Affiliated to Sackler Medical School, University of Tel Aviv , Israel , and
| | | | - Kevin Quach
- a CReATe Fertility Centre , Toronto , Ontario , Canada
| | - Clifford L Librach
- a CReATe Fertility Centre , Toronto , Ontario , Canada .,c Department of Obstetrics and Gynecology , University of Toronto , Ontario , Canada
| |
Collapse
|
49
|
Tremellen K, Zander-Fox D. Serum anti-Mullerian hormone assessment of ovarian reserve and polycystic ovary syndrome status over the reproductive lifespan. Aust N Z J Obstet Gynaecol 2015; 55:384-9. [PMID: 26230428 DOI: 10.1111/ajo.12366] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 05/16/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND To determine normal ranges for serum anti-Mullerian hormone (AMH) using the new automated Elecsys AMH assay platform, with a view to establishing values that signify premature loss of ovarian reserve, increased risk for an excessive response during IVF stimulation and a likely diagnosis of polycystic ovary syndrome (PCOS). MATERIALS AND METHODS Serum AMH was measured by the Elecsys automated electrochemiluminescence assay in 654 women undergoing gynaecological assessment. RESULTS Serum AMH levels peaked before 25 years of age, with mean AMH levels halving by 36 and falling to a quarter of their peak by 40 years of age. Overall, AMH results of 95% of patients with PCOS exceeded the 50th percentile for their age, with 72.1% having an AMH result in the top quartile for age. ROC analysis suggested that a serum AMH ≥36 pmol L(-1) is the best determinant of PCOS status (sensitivity 83.7% and specificity 82.3%). Serum AMH exhibited an excellent correlation with ultrasound-assessed antral follicle count (AFC) (r = 0.836, P < 0.0001), with a result of 20 pmol L(-1) corresponding to an AFC of 16 and, therefore, increased risk of ovarian hyperstimulation syndrome (OHSS) during IVF treatment. CONCLUSION Serum AMH is a sensitive marker of age-related decline in ovarian reserve status. A serum AMH result >36 pmol L(-1) , or above the 75th percentile for age, is highly suggestive of a diagnosis of PCOS. A serum AMH result below the 10th percentile for age suggests accelerated loss of ovarian reserve, while an AMH result exceeding 20 pmol L(-1) suggests an increased risk of OHSS during IVF treatment.
Collapse
Affiliation(s)
- Kelton Tremellen
- Repromed, Dulwich, South Australia, Australia.,Department of Obstetrics and Gynaecology, Flinders University, Bedford Park, South Australia, Australia
| | | |
Collapse
|
50
|
van der Linden M, Buckingham K, Farquhar C, Kremer JAM, Metwally M. Luteal phase support for assisted reproduction cycles. Cochrane Database Syst Rev 2015; 2015:CD009154. [PMID: 26148507 PMCID: PMC6461197 DOI: 10.1002/14651858.cd009154.pub3] [Citation(s) in RCA: 130] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Progesterone prepares the endometrium for pregnancy by stimulating proliferation in response to human chorionic gonadotropin(hCG) produced by the corpus luteum. This occurs in the luteal phase of the menstrual cycle. In assisted reproduction techniques(ART), progesterone and/or hCG levels are low, so the luteal phase is supported with progesterone, hCG or gonadotropin-releasing hormone (GnRH) agonists to improve implantation and pregnancy rates. OBJECTIVES To determine the relative effectiveness and safety of methods of luteal phase support provided to subfertile women undergoing assisted reproduction. SEARCH METHODS We searched databases including the Cochrane Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO and trial registers. We conducted searches in November 2014, and further searches on 4 August 2015. SELECTION CRITERIA Randomised controlled trials (RCTs) of luteal phase support using progesterone, hCG or GnRH agonist supplementation in ART cycles. DATA COLLECTION AND ANALYSIS Three review authors independently selected trials, extracted data and assessed risk of bias. We calculated odds ratios (ORs) and 95%confidence intervals (CIs) for each comparison and combined data when appropriate using a fixed-effect model. Our primary out come was live birth or ongoing pregnancy. The overall quality of the evidence was assessed using GRADE methods. MAIN RESULTS Ninety-four women RCTs (26,198 women) were included. Most studies had unclear or high risk of bias in most domains. The main limitations in the evidence were poor reporting of study methods and imprecision due to small sample sizes.1. hCG vs placebo/no treatment (five RCTs, 746 women)There was no evidence of differences between groups in live birth or ongoing pregnancy (OR 1.67, 95% CI 0.90 to 3.12, three RCTs,527 women, I2 = 24%, very low-quality evidence, but I2 of 61% was found for the subgroup of ongoing pregnancy) with a random effects model. hCG increased the risk of ovarian hyperstimulation syndrome (OHSS) (1 RCT, OR 4.28, 95% CI 1.91 to 9.6, low quality evidence).2. Progesterone vs placebo/no treatment (eight RCTs, 875 women)Evidence suggests a higher rate of live birth or ongoing pregnancy in the progesterone group (OR 1.77, 95% CI 1.09 to 2.86, five RCTs, 642 women, I2 = 35%, very low-quality evidence). OHSS was not reported.3. Progesterone vs hCG regimens (16 RCTs, 2162 women)hCG regimens included comparisons of progesterone versus hCG and progesterone versus progesterone + hCG. No evidence showed differences between groups in live birth or ongoing pregnancy (OR 0.95, 95% CI 0.65 to 1.38, five RCTs, 833 women, I2 = 0%, low quality evidence) or in the risk of OHSS (four RCTs, 615 women, progesterone vs hCG OR 0.54, 95% CI 0.22 to 1.34; four RCTs,678 women; progesterone vs progesterone plus hCG, OR 0.34, 95% CI 0.09 to 1.26, low-quality evidence).4. Progesterone vs progesterone with oestrogen (16 RCTs, 2577 women)No evidence was found of differences between groups in live birth or ongoing pregnancy (OR 1.12, 95% CI 0.91 to 1.38, nine RCTs,1651 women, I2 = 0%, low-quality evidence) or OHSS (OR 0.56, 95% CI 0.2 to 1.63, two RCTs, 461 women, I2 = 0%, low-quality evidence).5. Progesterone vs progesterone + GnRH agonist (seven RCTs, 1708 women)Live birth or ongoing pregnancy rates were lower in the progesterone-only group and increased in women who received progester one and one or more GnRH agonist doses (OR 0.62, 95% CI 0.48 to 0.81, nine RCTs, 2861 women, I2 = 55%, random effects, low quality evidence). Statistical heterogeneity for this comparison was high because of unexplained variation in the effect size, but the direction of effect was consistent across studies. OHSS was reported in one study only (OR 1.00, 95% CI 0.33 to 3.01, 1 RCT, 300 women, very low quality evidence).6. Progesterone regimens (45 RCTs, 13,814 women)The included studies reported nine different comparisons between progesterone regimens. Findings for live birth or ongoing pregnancy were as follows: intramuscular (IM) versus oral: OR 0.71, 95% CI 0.14 to 3.66 (one RCT, 40 women, very low-quality evidence);IM versus vaginal/rectal: OR 1.24, 95% CI 1.03 to 1.5 (seven RCTs, 2309 women, I2 = 71%, very low-quality evidence); vaginal/rectal versus oral: OR 1.19, 95% CI 0.83 to 1.69 (four RCTs, 857 women, I2 = 32%, low-quality evidence); low-dose versus high-dose vaginal: OR 0.97, 95% CI 0.84 to 1.11 (five RCTs, 3720 women, I2 = 0%, moderate-quality evidence); short versus long protocol:OR 1.04, 95% CI 0.79 to 1.36 (five RCTs, 1205 women, I2 = 0%, low-quality evidence); micronised versus synthetic: OR 0.9, 95%CI 0.53 to 1.55 (two RCTs, 470 women, I2 = 0%, low-quality evidence); vaginal ring versus gel: OR 1.09, 95% CI 0.88 to 1.36 (oneRCT, 1271 women, low-quality evidence); subcutaneous versus vaginal gel: OR 0.92, 95% CI 0.74 to 1.14 (two RCTs, 1465 women,I2 = 0%, low-quality evidence); and vaginal versus rectal: OR 1.28, 95% CI 0.64 to 2.54 (one RCT, 147 women, very low-quality evidence). OHSS rates were reported for only two of these comparisons: IM versus oral, and low versus high-dose vaginal. No evidence showed a difference between groups.7. Progesterone and oestrogen regimens (two RCTs, 1195 women)The included studies compared two different oestrogen protocols. No evidence was found to suggest differences in live birth or ongoing pregnancy rates between a short and a long protocol (OR 1.08, 95% CI 0.81 to 1.43, one RCT, 910 women, low-quality evidence) or between a low dose and a high dose of oestrogen (OR 0.65, 95% CI 0.37 to 1.13, one RCT, 285 women, very low-quality evidence).Neither study reported OHSS. AUTHORS' CONCLUSIONS Both progesterone and hCG during the luteal phase are associated with higher rates of live birth or ongoing pregnancy than placebo.The addition of GnRHa to progesterone is associated with an improvement in pregnancy outcomes. OHSS rates are increased with hCG compared to placebo (only study only). The addition of oestrogen does not seem to improve outcomes. The route of progester one administration is not associated with an improvement in outcomes.
Collapse
Affiliation(s)
- Michelle van der Linden
- Radboud University Medical CenterDepartment of Obstetrics and GynaecologyPO Box 9101NijmegenNetherlands6500 HB
| | | | - Cindy Farquhar
- University of AucklandDepartment of Obstetrics and GynaecologyFMHS Park RoadGraftonAucklandNew Zealand1003
| | - Jan AM Kremer
- Radboud University Nijmegen Medical CenterDepartment of Obstetrics and GynaecologyPO Box 9101NijmegenNetherlands6500 HB
| | - Mostafa Metwally
- Sheffield Teaching HospitalsThe Jessop Wing and Royal Hallamshire HospitalSheffieldUKS10 2JF
| | | |
Collapse
|