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Humaidan P, Kol S, Papanikolaou EG. GnRH agonist for triggering of final oocyte maturation: time for a change of practice? Hum Reprod Update 2011; 17:510-24. [PMID: 21450755 DOI: 10.1093/humupd/dmr008] [Citation(s) in RCA: 229] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND GnRH agonist (GnRHa) triggering has been shown to significantly reduce the occurrence of ovarian hyperstimulation syndrome (OHSS) compared with hCG triggering; however, initially a poor reproductive outcome was reported after GnRHa triggering, due to an apparently uncorrectable luteal phase deficiency. Therefore, the challenge has been to rescue the luteal phase. Studies now report a luteal phase rescue, with a reproductive outcome comparable to that seen after hCG triggering. METHODS This narrative review is based on expert presentations and subsequent group discussions supplemented with publications from literature searches and the authors' knowledge. Moreover, randomized controlled trials (RCTs) were identified and analysed either in fresh IVF cycles with embryo transfer (ET), oocyte donation cycles or cycles without ET; risk differences were calculated regarding pregnancy rate and OHSS rate. RESULTS In fresh IVF cycles with ET (9 RCTs) no OHSS was reported after GnRHa triggering [0% incidence in the GnRHa group: risk difference 5% (with 95% CI: -0.07 to 0.02)]. Importantly, the delivery rate improved significantly after modified luteal support [6% risk difference in favour of the HCG group (95% CI: -0.14 to 0.2)] when compared with initial studies with conventional luteal support [18% risk difference (95% CI: -0.36 to 0.01)]. In oocyte donation cycles (4 RCTs) the OHSS incidence is 0% [10% risk difference (95% CI: 0.02-0.40)]. CONCLUSIONS GnRHa triggering is a valid alternative to hCG triggering, resulting in an elimination of OHSS. After modified luteal support there is now a non-significant difference of 6% in delivery rate in favour of hCG triggering.
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Affiliation(s)
- P Humaidan
- The Fertility Clinic, Skive Regional Hospital, Resenvej 25, Skive, Denmark.
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103
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Dechanet C, Castelli C, Reyftmann L, Hamamah S, Hedon B, Dechaud H, Anahory T. Do female translocations influence the ovarian response pattern to controlled ovarian stimulation in preimplantation genetic diagnosis? Hum Reprod 2011; 26:1232-40. [DOI: 10.1093/humrep/der032] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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104
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Fauser BCJM, Alper MM, Ledger W, Schoolcraft WB, Zandvliet A, Mannaerts BMJL. Pharmacokinetics and follicular dynamics of corifollitropin alfa versus recombinant FSH during ovarian stimulation for IVF. Reprod Biomed Online 2011; 22 Suppl 1:S23-31. [DOI: 10.1016/s1472-6483(11)60006-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Revised: 05/27/2010] [Accepted: 06/17/2010] [Indexed: 11/15/2022]
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105
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Garcia-Velasco JA, Bennink HJTC, Epifanio R, Escudero E, Pellicer A, Simón C. High-dose recombinant LH add-back strategy using high-dose GnRH antagonist is an innovative protocol compared with standard GnRH antagonist. Reprod Biomed Online 2011; 22 Suppl 1:S52-9. [DOI: 10.1016/s1472-6483(11)60009-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2006] [Revised: 09/20/2006] [Accepted: 06/20/2007] [Indexed: 10/18/2022]
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106
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Fauser BC, Alper MM, Ledger W, Schoolcraft WB, Zandvliet A, Mannaerts BM. Pharmacokinetics and follicular dynamics of corifollitropin alfa versus recombinant FSH during ovarian stimulation for IVF. Reprod Biomed Online 2010; 21:593-601. [DOI: 10.1016/j.rbmo.2010.06.032] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Revised: 05/27/2010] [Accepted: 06/17/2010] [Indexed: 11/26/2022]
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Messinis IE, Messini CI, Dafopoulos K. The role of gonadotropins in the follicular phase. Ann N Y Acad Sci 2010; 1205:5-11. [DOI: 10.1111/j.1749-6632.2010.05660.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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108
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Kolibianakis EM, Venetis CA, Kalogeropoulou L, Papanikolaou E, Tarlatzis BC. Fixed versus flexible gonadotropin-releasing hormone antagonist administration in in vitro fertilization: a randomized controlled trial. Fertil Steril 2010; 95:558-62. [PMID: 20637457 DOI: 10.1016/j.fertnstert.2010.05.052] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Revised: 05/13/2010] [Accepted: 05/14/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To evaluate whether the incidence of luteinizing hormone (LH) rise is reduced by using a flexible compared with a fixed day-6 protocol of GnRH antagonist administration. DESIGN Randomized controlled trial. SETTING Tertiary university hospital. PATIENT(S) Patients undergoing in vitro fertilization (n = 146). INTERVENTION(S) Ovarian stimulation was performed using recombinant FSH and GnRH antagonists. GnRH antagonist cetrorelix (0.25 mg/d) was started either on day 6 of stimulation (fixed group) or when LH was >10 IU/L, and/or a follicle with mean diameter >12 mm was present, and/or serum E(2) was >150 pg/mL. Patient monitoring was initiated on day 3 of stimulation. MAIN OUTCOME MEASURE(S) Incidence of LH rise. RESULT(S) No statistically significant difference was observed between the flexible and fixed groups regarding the incidence of LH rise, which was lower in the flexible group (11.0% vs. 15.1%, difference -4.1%, 95% confidence interval -15.4% to +7.1%). No LH surges were observed in any of the patients studied. CONCLUSION(S) Flexible antagonist administration from day 3 onward does not appear to reduce the incidence of LH rises compared with fixed antagonist administration on day 6 of stimulation.
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Affiliation(s)
- Efstratios M Kolibianakis
- Unit for Human Reproduction, First Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Preventing ovarian hyperstimulation syndrome: guidance for the clinician. Fertil Steril 2010; 94:389-400. [PMID: 20416867 DOI: 10.1016/j.fertnstert.2010.03.028] [Citation(s) in RCA: 179] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2009] [Revised: 12/21/2009] [Accepted: 03/09/2010] [Indexed: 11/22/2022]
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Hosseini MA, Aleyasin A, Saeedi H, Mahdavi A. Comparison of gonadotropin-releasing hormone agonists and antagonists in assisted reproduction cycles of polycystic ovarian syndrome patients. J Obstet Gynaecol Res 2010; 36:605-10. [DOI: 10.1111/j.1447-0756.2010.01247.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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112
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Dose Selection of Corifollitropin Alfa by Modeling and Simulation in Controlled Ovarian Stimulation. Clin Pharmacol Ther 2010; 88:79-87. [DOI: 10.1038/clpt.2010.54] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Tehraninejad ES, Nasiri R, Rashidi B, Haghollahi F, Ataie M. Comparison of GnRH antagonist with long GnRH agonist protocol after OCP pretreatment in PCOs patients. Arch Gynecol Obstet 2010; 282:319-25. [DOI: 10.1007/s00404-010-1429-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2009] [Accepted: 03/08/2010] [Indexed: 12/18/2022]
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Tremellen KP, Lane M. Avoidance of weekend oocyte retrievals during GnRH antagonist treatment by simple advancement or delay of hCG administration does not adversely affect IVF live birth outcomes. Hum Reprod 2010; 25:1219-24. [PMID: 20215127 DOI: 10.1093/humrep/deq059] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- K P Tremellen
- Repromed, 180 Fullarton Road, Dulwich, SA 5065, Australia.
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Pandian Z, McTavish AR, Aucott L, Hamilton MP, Bhattacharya S. Interventions for 'poor responders' to controlled ovarian hyper stimulation (COH) in in-vitro fertilisation (IVF). Cochrane Database Syst Rev 2010:CD004379. [PMID: 20091563 DOI: 10.1002/14651858.cd004379.pub3] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The success of in-vitro fertilisation (IVF) depends on adequate follicle recruitment by using controlled ovarian stimulation with gonadotrophins. Failure to recruit adequate follicles is called 'poor response'. Various treatment protocols have been proposed that are targeted at this cohort of women, aiming to increase their ovarian response. OBJECTIVES To compare the effectiveness of different treatment interventions in women who have poor response to controlled ovarian hyperstimulation (are poor responders) in the context of IVF. SEARCH STRATEGY We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials (MDSG) (5/1/2009), the Cochrane Central Register of Controlled trials (CENTRAL) (4th Quarter 2008), MEDLINE (1950 to November week 3 2008), EMBASE (1980 to 2008 week 52) and The National Research Register (NRR). The citation lists of relevant publications, review articles, abstracts of scientific meetings and included studies were also searched. The authors were contacted to clarify data that were unclear from the trial reports. SELECTION CRITERIA Only randomised controlled trials (RCTs) comparing one type of intervention versus another for controlled ovarian stimulation of poor responders to a previous IVF treatment, using a standard long protocol were included. DATA COLLECTION AND ANALYSIS Two reviewers independently scanned the abstracts, identified relevant papers, assessed trial quality and extracted relevant data for inclusion. Validity was assessed in terms of method of randomisation, completeness of treatment cycle and co-intervention. Where possible, data were pooled for analysis. MAIN RESULTS The new search identified fifteen trials. Three trials were eligible for inclusion. Ten trials involving eight different comparison groups have been included. Only one trial reported live birth rates.The number of oocytes retrieved were significantly less in the conventional GnRHa long protocol compared to stop protocol and GnRH antagonist protocol.Total dose of gonadotrophins used was significantly higher in the GnRHa long protocol group compared to the Stop protocol and GnRH antagonist groups.Cancellation rates were significantly higher in the GnRHa flare up group compared to the GnRHa long protocol group.None of the studies reported a difference in the miscarriage and ectopic pregnancy rates. AUTHORS' CONCLUSIONS There is insufficient evidence to support the routine use of any particular intervention either for pituitary down regulation, ovarian stimulation or adjuvant therapy in the management of poor responders to controlled ovarian stimulation in IVF. More robust data from good quality RCTs with relevant outcomes are needed.
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Affiliation(s)
- Zabeena Pandian
- Obstetrics & Gynaecology, Aberdeen Maternity Hospital, Foresterhill, Aberdeen, UK, AB25 2ZD
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116
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Are gonadotropin-releasing hormone agonists losing popularity? Current trends at a large fertility center. Fertil Steril 2010; 93:101-8. [DOI: 10.1016/j.fertnstert.2008.09.048] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Revised: 09/09/2008] [Accepted: 09/11/2008] [Indexed: 11/23/2022]
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117
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Microdose gonadotropin-releasing hormone agonist flare-up protocol versus multiple dose gonadotropin-releasing hormone antagonist protocol in poor responders undergoing intracytoplasmic sperm injection–embryo transfer cycle. Fertil Steril 2009; 91:2437-44. [DOI: 10.1016/j.fertnstert.2008.03.057] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2007] [Revised: 03/23/2008] [Accepted: 03/24/2008] [Indexed: 11/22/2022]
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118
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Meldrum DR, Scott Jr. RT, Levy MJ, Alper MM, Noyes N. Oral contraceptive pretreatment in women undergoing controlled ovarian stimulation in ganirelix acetate cycles may, for a subset of patients, be associated with low serum luteinizing hormone levels, reduced ovarian response to gonadotropins, and early pregnancy loss. Fertil Steril 2009; 91:1963-5. [DOI: 10.1016/j.fertnstert.2008.01.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2007] [Revised: 12/27/2007] [Accepted: 01/02/2008] [Indexed: 10/22/2022]
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119
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Depalo R, Lorusso F, Palmisano M, Bassi E, Totaro I, Vacca M, Trerotoli P, Masciandaro P, Selvaggi L. Follicular growth and oocyte maturation in GnRH agonist and antagonist protocols for in vitro fertilisation and embryo transfer. Gynecol Endocrinol 2009; 25:328-34. [PMID: 19340626 DOI: 10.1080/09513590802617762] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND The aim of this study was to evaluate the response to treatment in a group of patients undergoing IVF and randomised to receive GnRH-antagonist or the GnRH-agonist. The endpoints were the pattern of follicular growth, the maturity of the oocytes collected, the embryo quality and the pregnancy outcome. METHODS A total of 136 patients undergoing IVF were included. Sixty-seven patients were allocated to the GnRH antagonist and 69 patients to the GnRH agonist. GnRH antagonist was administered when the leading follicle reached a diameter of 12-14 mm. GnRH agonist was administered in a long luteal protocol. RESULTS The mean numbers of oocytes retrieved and mature oocytes were significantly higher in the agonist than in the antagonist group (p < 0.02 and p < 0.01, respectively). Embryo quality, implantation rate, clinical pregnancy rates, ongoing pregnancy rate and miscarriage rate were similar in both groups. CONCLUSIONS Better follicular growth and oocyte maturation are achieved with GnRH agonist treatment. However, both regimens seem to have similar efficacy in terms of implantation and pregnancy rates. Further studies clarifying the effect of the GnRH antagonist on ovarian function are needed, as well as a clear definition of the best period of the follicular phase for the GnRH antagonist administration.
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Affiliation(s)
- Raffaella Depalo
- Department of Gynecology, Obstetrics and Neonatology, Gynecology and Obstetric Unit A, University of Bari, Piazza Giulio Cesare, Bari, Italy
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Giles J, Requena A, García-Velasco JA, Pacheco A, Pellicer J, Pellicer A. GnRH analogue for the prevention of ovarian hyperstimulation syndrome: a pilot study. Fertil Steril 2009; 91:1366-9. [DOI: 10.1016/j.fertnstert.2008.04.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2006] [Revised: 04/09/2008] [Accepted: 04/09/2008] [Indexed: 10/21/2022]
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121
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Verberg MFG, Eijkemans MJC, Macklon NS, Heijnen EMEW, Baart EB, Hohmann FP, Fauser BCJM, Broekmans FJ. The clinical significance of the retrieval of a low number of oocytes following mild ovarian stimulation for IVF: a meta-analysis. Hum Reprod Update 2009; 15:5-12. [PMID: 19091754 DOI: 10.1093/humupd/dmn053] [Citation(s) in RCA: 161] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Milder ovarian stimulation protocols for in vitro fertilization (IVF) are being developed to minimize adverse effects. Mild stimulation regimens result in a decreased number of oocytes at retrieval. After conventional ovarian stimulation for IVF, a low number of oocytes are believed to represent poor ovarian reserve resulting in reduced success rates. Recent studies suggest that a similar response following mild stimulation is associated with better outcomes. METHODS This review investigates whether the retrieval of a low number of oocytes following mild ovarian stimulation is associated with impaired implantation rates. Three randomized controlled trials comparing the efficacy of the mild ovarian stimulation regimen (involving midfollicular phase initiation of FSH and GnRH co-treatment) for IVF with a conventional long GnRH agonist co-treatment stimulation protocol could be identified by means of a systematic literature search. RESULTS These studies comprised a total of 592 first treatment cycles. Individual patient data analysis showed that the mild stimulation protocol results in a significant reduction of retrieved oocytes compared with conventional ovarian stimulation (median 6 versus 9, respectively, P < 0.001). Optimal embryo implantation rates were observed with 5 oocytes retrieved following mild stimulation (31%) versus 10 oocytes following conventional stimulation (29%) (P = 0.045). CONCLUSIONS The optimal number of retrieved oocytes depends on the ovarian stimulation regimen. After mild ovarian stimulation, a modest number of oocytes is associated with optimal implantation rates and does not reflect a poor ovarian response. Therefore, the fear of reducing the number of oocytes retrieved following mild ovarian stimulation appears to be unjustified.
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Affiliation(s)
- M F G Verberg
- Department of Reproductive Medicine and Gynaecology, University Medical Center, Utrecht, The Netherlands.
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122
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Vrtacnik-Bokal E, Virant Klun I, Verdenik I. Follicular oestradiol and VEGF after GnRH antagonists or GnRH agonists in women with PCOS. Reprod Biomed Online 2009; 18:21-8. [PMID: 19146765 DOI: 10.1016/s1472-6483(10)60420-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The aim of this study was to determine whether follicular oestradiol and vascular endothelial growth factor (VEGF) concentrations in women with polycystic ovarian syndrome (PCOS) differ according to the use of gonadotrophin-releasing hormone (GnRH) antagonists or GnRH agonists. Furthermore, the effect of follicular oestradiol and VEGF concentrations on oocyte and embryo quality was investigated. In this prospective clinical study, 20 women with PCOS undergoing intracytoplasmic sperm injection for male factor infertility were included using a GnRH antagonist or a GnRH agonist protocol. In each follicle, oestradiol and VEGF concentrations were determined. In the GnRH antagonist group 254 follicles and in the GnRH agonist group 245 follicles, were aspirated. Fewer metaphase II (MII) and more immature and degenerative oocytes were registered in the GnRH antagonist group. Follicular oestradiol and VEGF were lower in the GnRH antagonist group (P = 0.014 and P < 0.001, respectively). Moreover, higher oestradiol concentrations were related to embryos of higher quality (P = 0.037). It is concluded that GnRH antagonists decrease follicular oestradiol and VEGF concentrations and the number of retrieved MII oocytes in women with PCOS.
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Affiliation(s)
- Eda Vrtacnik-Bokal
- Department of Obstetrics and Gynecology, Reproductive Unit, University Medical Centre Ljubljana, Ljubljana, Slovenia.
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IVF/ICSI outcomes between cycles with luteal estradiol (E2) pre-treatment before GnRH antagonist protocol and standard long GnRH agonist protocol: a prospective and randomized study. J Assist Reprod Genet 2009; 26:105-11. [PMID: 19225876 DOI: 10.1007/s10815-009-9300-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2008] [Accepted: 01/23/2009] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE To study if luteal E(2) pre-treatment before GnRH antagonist protocol improves IVF/ICSI outcomes compared with standard long GnRH agonist protocol. DESIGN A prospective, randomized and controlled study. SETTING ART center of a state public hospital PATIENT(S) Two hundred twenty infertile women underwent IVF/ICSI treatments. INTERVENTION(S) Participants received oral Estradiol Valerate 4 mg/day preceding the IVF cycle from day 21 until day 2 of next cycle before GnRH antagonist protocol (E(2) pre-treatment group n=109) or received standard long GnRH agonist protocol as control group (n=111). MAIN OUTCOME MEASURE(S) Number of oocytes collected, MII oocytes, fertilization, implantation, live birth and early pregnancy rate, and hormone profiles. RESULT(S) E(2) pre-treatment exerted a significant suppressive effect on FSH but not LH secretion compared with basal FSH and LH levels. In E(2) pre-treatment group serum LH level was significantly higher during COH and serum P was also significantly higher on the day of HCG injection compared with control group. Five patients from E(2) pre-treatment group had elevated LH at all time (>or= 10 IU/L) and also a concomitantly high P (>1 ng/mL). Two of the five women achieved pregnancy but had early pregnancy loss. Overall, IVF/ICSI outcomes such as implantation, clinical pregnancy and live birth rates were similar between E(2) pre-treatment and control groups. CONCLUSION(S) Luteal E(2) pre-treatment before GnRH antagonist protocol significantly increases serum LH level and incidence rate of premature LH but no significant effect is observed on implantation, clinical pregnancy, live birth and early pregnancy loss rates compared with long GnRH agonist protocol. However, more studies in large numbers of cycles are needed to confirm that increased serum LH level by E(2) pre-treatment during COH has no negative effect on the IVF/ICSI outcomes.
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Nyachieo A, Spiessens C, Mwenda JM, Debrock S, D’Hooghe TM. Improving ovarian stimulation protocols for IVF in baboons: Lessons from humans and rhesus monkeys. Anim Reprod Sci 2009; 110:187-206. [DOI: 10.1016/j.anireprosci.2008.08.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2008] [Revised: 08/18/2008] [Accepted: 08/21/2008] [Indexed: 10/21/2022]
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Pinto F, Oliveira C, Cardoso MF, Teixeira-da-Silva J, Silva J, Sousa M, Barros A. Impact of GnRH ovarian stimulation protocols on intracytoplasmic sperm injection outcomes. Reprod Biol Endocrinol 2009; 7:5. [PMID: 19146685 PMCID: PMC2633006 DOI: 10.1186/1477-7827-7-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2008] [Accepted: 01/15/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although a large number of studies have been conducted in relation to ovarian response and pregnancy after GnRH agonist and GnRH antagonist controlled ovarian hyperstimulation protocols, most of them used single or combinations of a few predictive factors, and none included the stimulation protocol in the multivariable analysis. The present study was thus primarily designed to investigate the predictive value of the stimulation protocol and to analyze the possible relationships between stimulation protocols and treatment outcomes after adjusting for a large set of variables that potentially affect reproductive outcomes. Factors related to pregnancy achievement and predictive of the number of oocytes retrieved and high quality of the embryos obtained were also analyzed. METHODS To analyze the impact of GnRH ovarian stimulation protocols on the independent predictors of ovarian response, high quality embryos and clinical pregnancy, two groups out of 278 ICSI treatment cycles were compared prospectively, 123 with a GnRH agonist and 155 with a GnRH antagonist, with multivariable analysis assessing outcomes after adjusting for a large set of variables. RESULTS Antagonists were significantly associated with lower length and total dose of GnRH, lower length of rFSH, and higher numbers of oocytes and high quality embryos, whereas the agonist presented a higher fertilization rate and probability of pregnancy. Significant predictors of retrieved oocytes and high quality embryos were the antagonist protocol, lower female age, lower serum levels of basal FSH and higher total number of antral follicles. Significant predictors of clinical pregnancy were the agonist protocol, reduced number of attempts, increased endometrial thickness and lower female age. The probability of pregnancy increased until 30 years-old, with a decline after that age and with a sharp decline after 40 years-old. CONCLUSION The models found suggest that not only the protocol but also factors as female age, basal FSH, antral follicles, number of attempts and endometrial thickness should be analyzed for counselling patients undergoing an ICSI treatment.
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Affiliation(s)
- Fátima Pinto
- Faculty of Engineering, University of Porto, Porto, Portugal
| | | | - Margarida F Cardoso
- Department of Population Studies, ICBAS-Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
| | | | - Joaquina Silva
- Centre for Reproductive Genetics A. Barros, Porto, Portugal
| | - Mário Sousa
- Centre for Reproductive Genetics A. Barros, Porto, Portugal
- Lab Cell Biology, ICBAS-Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
- Department of Genetics, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Alberto Barros
- Centre for Reproductive Genetics A. Barros, Porto, Portugal
- Department of Genetics, Faculty of Medicine, University of Porto, Porto, Portugal
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GnRH antagonists and endometrial receptivity in oocyte recipients: a prospective randomized trial. Reprod Biomed Online 2009; 18:276-81. [DOI: 10.1016/s1472-6483(10)60266-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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128
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Baart EB, Macklon NS, Fauser BJCM. Ovarian stimulation and embryo quality. Reprod Biomed Online 2009; 18 Suppl 2:45-50. [DOI: 10.1016/s1472-6483(10)60448-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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129
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Devroey P, Aboulghar M, Garcia-Velasco J, Griesinger G, Humaidan P, Kolibianakis E, Ledger W, Tomas C, Fauser BC. Improving the patient's experience of IVF/ICSI: a proposal for an ovarian stimulation protocol with GnRH antagonist co-treatment. Hum Reprod 2008; 24:764-74. [DOI: 10.1093/humrep/den468] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Detti L, Yelian FD, Kruger ML, Diamond MP, Puscheck EE. Endometrial thickness dynamics and morphologic characteristics during pituitary downregulation with antagonists in assisted reproductive technology cycles. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2008; 27:1591-1596. [PMID: 18946098 DOI: 10.7863/jum.2008.27.11.1591] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE The purpose of this study was to evaluate whether the dynamics of endometrial stripe thickness during gonadotropin-releasing hormone (GnRH) antagonist pituitary downregulation in in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles are related to implantation and pregnancy outcomes. METHODS This retrospective cohort study evaluated 115 conventional IVF/ICSI cycles. All patients underwent ovarian stimulation with gonadotropins and the GnRH antagonist ganirelix acetate. The endometrial stripe was measured transvaginally daily from the day of initial GnRH antagonist administration to the day of the human chorionic gonadotropin (hCG) trigger and then transabdominally on the day of embryo transfer. We created 5 categories (0-4) of endometrial thickness variation, considering significant a daily variation of 1.5 mm. Our aim was to predict whether the endometrial thickness dynamics or morphologic characteristics were related to the duration of ovarian stimulation, duration of ganirelix use, or estradiol levels during ovarian stimulation and whether they would influence implantation and pregnancy rates. RESULTS No relationship was found between the duration of ovarian stimulation, duration of ganirelix use, and estradiol level (expressed as the area under the curve), and endometrial thickness dynamics or morphologic characteristics. Despite a thinner endometrial thickness in 37% of the cycles on the day of the hCG trigger compared with the beginning of GnRH antagonist stimulation, there was no correlation between endometrial dynamics and pregnancy outcomes. There was, instead, a positive relationship between a trilaminar endometrial morphologic pattern with a positive pregnancy test result, successful implantation, and ongoing pregnancy (P < .05). CONCLUSIONS Despite a net decrease in thickness in almost 50% of cases, endometrial dynamics did not correlate with pregnancy outcomes. Conversely, a trilaminar endometrial morphologic pattern on the day of embryo transfer was positively related to pregnancy outcomes.
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Affiliation(s)
- Laura Detti
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Wayne State University School of Medicine, Detroit, MI 48201 USA.
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A randomized dose-response trial of a single injection of corifollitropin alfa to sustain multifollicular growth during controlled ovarian stimulation. Hum Reprod 2008; 23:2484-92. [DOI: 10.1093/humrep/den288] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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133
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Pasquier M, Maitrot L, Leperlier F, Dehghani C, Snaifer E, Durnerin IC, Hugues JN. [The use of GnRH antagonists in ovarian stimulation for intrauterine inseminations: is there any interest?]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2008; 36:644-649. [PMID: 18539072 DOI: 10.1016/j.gyobfe.2008.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2007] [Accepted: 03/30/2008] [Indexed: 05/26/2023]
Abstract
The use of the GnRH antagonists during ovarian stimulation for intrauterine insemination is relatively recent. The primary aim was to improve the timing of the inseminations on working days. However, according to published data, the consequences on pregnancy rate remain uncertain. Moreover, the impact of this strategy on stimulation's parameters, specifically on the size of the follicle cohort, should be better assessed.
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Affiliation(s)
- M Pasquier
- Service de médecine de la reproduction, université Paris-XIII, CHU Jean-Verdier, avenue du 14-Juillet, 93140 Bondy, France.
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Detti L, Ambler DR, Yelian FD, Kruger ML, Diamond MP, Puscheck EE. Timing and duration of use of GnRH antagonist down-regulation for IVF/ICSI cycles have no impact on oocyte quality or pregnancy outcomes. J Assist Reprod Genet 2008; 25:177-81. [PMID: 18461435 DOI: 10.1007/s10815-008-9217-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2008] [Accepted: 03/24/2008] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To evaluate whether oocyte quality, implantation and pregnancy outcomes in in vitro fertilization (IVF)/intra-cytoplasmic sperm injection (ICSI) are related to the duration of gonadotropin-releasing hormone (GnRH)-antagonist use or the timing of its initiation. METHODS Retrospective cohort study of 178 conventional IVF/ICSI cycles. All patients underwent ovarian stimulation with gonadotropins and GnRH-antagonist for pituitary down-regulation. Spearman correlations and logistic regression were used for statistical analysis. RESULTS There was no correlation between the duration of use or the timing of initiation of GnRH-antagonist with oocyte quality or implantation and pregnancy outcomes. Oocyte quality was influenced by the peak estradiol. Implantation was influenced by the patient's age. Early pregnancy loss, by the endometrial thickness on human chorionic gonadotropin-day. Ongoing pregnancy was independent from the variables evaluated. CONCLUSIONS GnRH-antagonist duration of use or starting day did not influence oocyte quality, implantation rates, and pregnancy rates. We hypothesize that a follicle stimulating hormone/luteinizing hormone dose increase when antagonist was started, may have had an impact on our findings.
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Affiliation(s)
- Laura Detti
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Wayne State University School of Medicine, 3750 Woodward Ave., Suite 200-D, Detroit, MI, 48201, USA.
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Comparisons of Different Dosages of Gonadotropin-Releasing Hormone (GnRH) Antagonist, Short-acting Form and Single, Half-dose, Long-acting Form of GnRH Agonist During Controlled Ovarian Hyperstimulation and in vitro Fertilization. Taiwan J Obstet Gynecol 2008; 47:66-74. [DOI: 10.1016/s1028-4559(08)60057-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Moraloglu O, Kilic S, Karayalçin R, Yuksel B, Tasdemir N, Işik A, Ugur M. Comparison of GnRH agonists and antagonists in normoresponder IVF/ICSI in Turkish female patients. Adv Ther 2008; 25:266-73. [PMID: 18345521 DOI: 10.1007/s12325-008-0028-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate the results of gonadotropin-releasing hormone agonist (GnRHa) and gonadotropin-releasing hormone antagonist (GnRHant) use in two demographically matched groups of normoresponder in-vitro fertilisation or intracytoplasmic sperm injection (IVF/ICSI) patients in a prospective study. METHODS We randomised 93 patients undergoing IVF/ICSI between May 2005 and August 2006. Patients with IVF indications were included except for those with polycystic ovary syndrome or azoospermia, women older than 38 years and those with follicle-stimulating hormone (FSH) > or =10 IU/ml. Patients were stimulated with standard 225 IU recombinant FSH. In Group I (n=45) a daily dose of GnRHant cetrorelix acetate 0.25 mg was administered when follicles reached a diameter of > or =14 mm. Group II (n=48) patients were desensitised with the GnRHa, leuprolide acetate, in a long protocol. Human chorionic gonadotropin (hCG) was administered when at least three follicles of 18 mm in diameter were observed. Oocyte retrieval was scheduled 36 hours following hCG administration and embryos were transferred on day 3 after oocyte retrieval. RESULTS The two groups were homogenous for age, infertility duration, basal FSH and serum oestradiol (E2) (P=0.537, P=0.911, P=0.103 and P=0.733, respectively). In Group II (the GnRHa group) more antral follicles (P<0.001), a longer induction duration (P=0.017) and higher peak E2 levels (P<0.001) were observed. No differences were observed in the number of oocytes retrieved (P=0.749), embryos achieved and transferred (P=0.677), or fertilisation rates (P=0.839) between the two groups. There was no statistically significant difference between groups in clinical pregnancy rates, cycle cancellation and ovarian hyperstimulation (P=0.437, P=0.109 and P=0.415, respectively). CONCLUSION GnRHant and GnRHa provide comparable results in normoresponder patients, while GnRHant allows a greater flexibility in their treatment.
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Affiliation(s)
- Ozlem Moraloglu
- Zekai Tahir Burak Women's Health and Education Hospital, Ankara, Turkey
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Bukulmez O, Carr BR, Doody KM, Doody KJ. Serum cetrorelix concentrations do not affect clinical pregnancy outcome in assisted reproduction. Fertil Steril 2008; 89:74-83. [PMID: 17662281 DOI: 10.1016/j.fertnstert.2007.02.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2006] [Revised: 02/12/2007] [Accepted: 02/12/2007] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To analyze the potential association between serum cetrorelix levels and clinical pregnancy outcome in patients who had undergone assisted reproduction cycles with a GnRH antagonist cetrorelix acetate 3-mg injection. DESIGN Retrospective case-control study. SETTING University-affiliated private-assisted reproduction center. PATIENT(S) 130 IVF and intracytoplasmic sperm injection first cycles, treated with the same cetrorelix acetate protocol, in two matched groups according to whether the cycle resulted in clinical pregnancy (n = 56) or not (n = 74). INTERVENTION(S) Cetrorelix acetate administration at 3 mg in a sandwich protocol. MAIN OUTCOME MEASURE(S) Serum cetrorelix concentrations on the day of hCG administration with regard to clinical pregnancy outcome, pre- versus post-hCG percent change in serum E(2) levels and implantation rates. RESULT(S) The cetrorelix serum concentrations were in the range of 0.29 to 5.12 ng/mL. The comparisons between groups with and without clinical pregnancy revealed comparable serum cetrorelix levels. There was no significant correlation between the serum cetrorelix concentrations and percent change in pre- versus post-hCG serum E(2) levels. Serum cetrorelix levels were comparable among patients with various implantation rates. CONCLUSION(S) Although a wide range of serum cetrorelix levels could be detected during a GnRH antagonist cycle, these levels were comparable in patients with and without clinical pregnancies.
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138
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Sirayapiwat P, Suwajanakorn S, Triratanachat S, Niruthisard S. The effects of GnRH antagonist on the endometrium of normally menstruating women. J Assist Reprod Genet 2007; 24:579-86. [PMID: 18049889 PMCID: PMC3455003 DOI: 10.1007/s10815-007-9184-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2007] [Accepted: 11/06/2007] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To study the effects of GnRH antagonist (ganirelix-Orgalutran) on the endometrium of regularly menstruating women. MATERIALS AND METHODS Prospective, self-controlled study. The thirty-five volunteers were studied for two cycles: one as a control and the other, GnRH antagonist-treated cycles in which ganirelix 0.25 mg/d was given daily for 3 days, starting when the largest follicle reached 15 mm. In both cycles, serum estradiol, LH and endometrial thickness were measured when the largest follicle was > or =18 mm. Endometrial biopsy was performed on day 6 after ovulation for histological dating and morphometric study. RESULTS No statistical differences between histological dating and the endometrial thickness in the control and GnRH antagonist-treated cycles. All morphometric parameters were also not different. Serum estradiol and LH levels were significantly lower in GnRH antagonist-treated cycles. CONCLUSION GnRH antagonist has no effect on the endometrium of regularly menstruating women as assessed by either histological dating or morphometric analysis.
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Affiliation(s)
- Porntip Sirayapiwat
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Rama IV Road, Bangkok, 10330, Thailand.
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139
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Barker MA, Christianson MS, Schouweiler CM, Lindheim SR. Clinical outcomes using a flexible regimen of GnRH-antagonists and a 'step-up' of additional gonadotropins in donor oocyte cycles. Curr Med Res Opin 2007; 23:2297-302. [PMID: 17697455 DOI: 10.1185/030079907x219689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the impact of serum estradiol upon oocyte donor cycle stimulation characteristics and clinical outcomes using flexible GnRH-antagonist (GnRH-ant) with additional FSH supplementation. RESEARCH DESIGN AND METHODS A retrospective chart review of 99 oocyte donor cycles using ovarian hyperstimulation with recombinant FSH (rFSH) and GnRH-ant was analyzed. Following discontinuation of oral contraceptives, controlled ovarian hyperstimulation was begun using rFSH (150-300 IU daily). GnRH-ant (ganirelix, Organon) and an additional 75 IU of FSH/day were begun when lead follicles were 13-14 mm in greatest diameter. Cycles were analyzed based on serum estradiol response following administration of GnRH-ant (Group 1: progressive rise and Group 2: no rise or a decline). Primary endpoints were cycle stimulation characteristics based on serum estradiol following GnRH-ant, clinical pregnancy and implantation rates. RESULTS A decline in serum estradiol was seen after GnRH-ant administration in 45% of cycles. Clinical pregnancy rates per transfer (70 vs. 72%) and implantation rates (43 vs. 56%) were similar for each group. CONCLUSION Flexible regimens of GnRH-ant even with additional rFSH in a 'step-up' fashion frequently result in a decline in serum estradiol during ovulation induction. While our study is non-randomized, it does not appear to result in any adverse affect in clinical outcomes in donor oocyte cycles.
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Affiliation(s)
- M A Barker
- Good Samaritan Hospital, Cincinnati, OH, USA
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140
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Cunha Filho JS, Terres LF, Holanda F, Freitas F, Glitz C, Genro VK, Arbo E. Luteal phase oestradiol administration in ovarian stimulation cycles with GnRH antagonist is comparable to the GnRH agonist (long) protocol. J Assist Reprod Genet 2007; 24:326-30. [PMID: 17636446 PMCID: PMC3454939 DOI: 10.1007/s10815-007-9125-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2006] [Accepted: 03/05/2007] [Indexed: 11/26/2022] Open
Abstract
PURPOSE The purpose of the study was to compare the effectiveness of GnRH antagonist with luteal phase estradiol administration to GnRH agonist cycles, long protocol. METHODS 55 IVF-ICSI patients received oestradiol in the luteal phase of the cycle, before a cycle with GnRH antagonist. Fifty-five patients submitted to IVF-ICSI with the use of agonist were allocated, age matched, as a control group (historical control). The primary outcome was the number of retrieved oocytes. RESULTS Patients were similar in terms of clinical characteristics. No differences were found in the number of oocytes retrieved (study group, 8.1 +/- 4.7; control group, 7.4 +/- 4.5) or in oocyte quality. CONCLUSIONS We clearly demonstrated that the effectiveness of GnRH antagonist when combined with luteal phase estradiol is comparable to GnRH agonist cycles.
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Affiliation(s)
- J S Cunha Filho
- Ob/Gyn depto., Hospital de Clínicas de Porto Alegre, Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcellos, 2350, Porto Alegre, RS, CEP 90035-003, Brazil.
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Al-Inany HG, Abou-Setta AM, Aboulghar M. Gonadotrophin-releasing hormone antagonists for assisted conception: a Cochrane review. Reprod Biomed Online 2007; 14:640-9. [PMID: 17509210 DOI: 10.1016/s1472-6483(10)61059-0] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Gonadotrophin-releasing hormone (GnRH) antagonists suppress gonadotrophin secretion resulting in dramatic reduction in treatment cycle duration. Assuming comparable clinical outcomes, these benefits may justify changing the standard long GnRH agonist protocol to GnRH antagonist regimens. To evaluate the evidence, databases (e.g. Cochrane Library, MEDLINE, EMBASE) were electronically searched, hand searches were performed, and manufacturers in the field were contacted. Twenty-seven randomized controlled trials (RCT) fulfilled inclusion criteria for comparison of GnRH antagonist with long GnRH agonist protocol. Clinical pregnancy rate and ongoing pregnancy/live-birth rate were significantly lower in the antagonist group (P = 0.009; OR = 0.83, 95% CI 0.72-0.95 and P = 0.02; OR = 0.82, 95% CI 0.68-0.97 respectively). Conversely, incidence of severe OHSS was significantly reduced with the antagonist protocol (P = 0.01; OR = 0.60, 95% CI 0.40-0.88), and interventions to prevent OHSS were administered more frequently in the agonist group (P = 0.03; OR = 0.43, 95% CI 0.20-0.92). Concluding, GnRH antagonist protocols are short, simple, with good clinical outcomes and significant reduction in severe OHSS incidence and gonadotrophin amount; however, the lower pregnancy rate compared with the GnRH agonist long protocol necessitates counselling subfertile couples before recommending change from GnRH agonist to antagonist.
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Affiliation(s)
- H G Al-Inany
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Cairo University, 8 Moustapha Hassanin Street, Manial, Cairo, Egypt.
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Cantineau AEP, Cohlen BJ. The prevalence and influence of luteinizing hormone surges in stimulated cycles combined with intrauterine insemination during a prospective cohort study. Fertil Steril 2007; 88:107-12. [PMID: 17445811 DOI: 10.1016/j.fertnstert.2006.11.136] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2006] [Revised: 11/09/2006] [Accepted: 11/21/2006] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To reveal the prevalence of premature LH surges in an IUI program. Furthermore, to investigate whether these LH surges influence treatment outcome and whether the prevalence of LH surges differs between cycles stimulated with clomiphene citrate (CC) and cycles stimulated with recombinant follicle-stimulating hormone (rFSH). DESIGN Prospective cohort study. SETTING Subfertility patients in a tertiary institutional hospital. PATIENT(S) A total of 66 subfertile couples undergoing ovarian hyperstimulation combined with IUI. INTERVENTION(S) The women were randomized through a central blocked computer system, either to receive CC (33 couples) or rFSH (33 couples), both combined with IUI. Blood for LH determination was drawn on the day of human chorionic gonadotropin administration. MAIN OUTCOME MEASURE(S) LH surges as well as pregnancy rates. RESULT(S) In a total of 153 cycles, LH was measured. In 36% of these cycles, LH surges were detected. The results showed that in 42% of the rFSH-stimulated cycles an LH surge was detected, compared with 30% in the cycles with CC (odds ratio 1.7, 95% confidence interval 0.9 to 3.3). There was a nonsignificant trend showing higher pregnancy rates in cycles without an LH surge (odds ratio 2.7, 95% confidence interval 0.6 to 13). CONCLUSION(S) Premature LH surges occur frequently, and they might influence treatment outcome negatively. Strategies to improve treatment outcome might focus on preventing premature LH surges.
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Affiliation(s)
- Astrid E P Cantineau
- Subfertility Unit, Department of Obstetrics and Gynaecology, Isala Clinics, Zwolle, The Netherlands.
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Rabinson J, Meltcer S, Zohav E, Gemer O, Anteby EY, Orvieto R. GnRH agonist versus GnRH antagonist in ovarian stimulation: the influence of body mass index on in vitro fertilization outcome. Fertil Steril 2007; 89:472-4. [PMID: 17582402 DOI: 10.1016/j.fertnstert.2007.03.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2007] [Revised: 03/05/2007] [Accepted: 03/05/2007] [Indexed: 11/30/2022]
Abstract
In an attempt to examine whether body mass index (BMI) may influence IVF outcome in patients undergoing COH with either GnRH-agonist (agonist group) or GnRH-antagonist (antagonist group), we studied 799 IVF cycles: 481 in the agonist group and 318 in the antagonist group. In patients with BMI >25 kg/m(2), COH with either GnRH-agonist or GnRH-antagonist achieved a comparable outcome; whereas in patients with BMI <25 kg/m(2), the use of GnRH-agonist suppressive protocol revealed significantly higher pregnancy rates.
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Affiliation(s)
- Jacob Rabinson
- Department of Obstetrics and Gynecology, Barzilai Medical Center, Ashkelon, Israel
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Fisch JD, Keskintepe L, Sher G. Gonadotropin-releasing hormone agonist/antagonist conversion with estrogen priming in low responders with prior in vitro fertilization failure. Fertil Steril 2007; 89:342-7. [PMID: 17562336 DOI: 10.1016/j.fertnstert.2007.03.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2006] [Revised: 03/02/2007] [Accepted: 03/02/2007] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate gonadotropin-releasing hormone (GnRH) agonist/antagonist conversion with estrogen priming (AACEP) in low responders with prior IVF failure. DESIGN Descriptive. SETTING Private practice. PATIENT(S) Women aged <or=42 with prior IVF attempts in which all embryos were <7 cells or >20% fragmentation on day 3 (n = 137; <38: n = 63; 38-42: n = 74). In addition to unexplained poor response to stimulation (n = 52), diagnoses included elevated follicle-stimulating hormone (FSH >9.0 mIU/mL; n = 40), advanced age (>41 years; n = 26), endometriosis (III-IV; n = 12), and decreased ovarian reserve (AFC <5; n = 7). INTERVENTION(S) Patients received sequential GnRH agonist, low-dose GnRH antagonist, and estradiol valerate followed by recombinant FSH, 600 IU/day (n = 72) or 750 IU/day (n = 65). MAIN OUTCOME MEASURE(S) Pregnancy, ongoing gestation, implantation rates. RESULT(S) Although women aged <38 years and those on 600 IU/day produced more mature eggs and fertilized embryos than women aged 38 to 42 years, there were no differences in peak estradiol, endometrial lining, or embryos transferred. Outcomes were similar for all patients regardless of age or FSH dosage. Ongoing gestation rates were 27% (37 out of 137) for all patients, 25% (16 out of 63) for age <38 years, and 28% (21 out of 74) for ages 38 to 42 years. CONCLUSION(S) Women aged <or=42 years who are candidates for oocyte donation may still achieve pregnancy using their own eggs with the AACEP protocol.
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Affiliation(s)
- Jeffrey D Fisch
- Sher Institute for Reproductive Medicine, Las Vegas, Nevada 89109, USA.
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145
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Wang JG, Douglas NC, Dicken C, Nakhuda GS, Guarnaccia MM, Sauer MV. Cryopreservation of supernumerary high quality embryos predicts favorable outcomes for patients undergoing repeated cycles of in vitro fertilization. Fertil Steril 2007; 89:368-74. [PMID: 17509594 DOI: 10.1016/j.fertnstert.2007.03.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2006] [Revised: 02/20/2007] [Accepted: 03/08/2007] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine whether the decline in pregnancy and implantation rates in repeated fresh IVF cycles is associated with the availability of embryo cryopreservation. DESIGN Retrospective study. SETTING Assisted reproductive unit at an academic institution. PATIENT(S) Women <38 years old (1,037), undergoing nondonor fresh or frozen embryo transfer (FET) cycles between January 1, 2000 and December 31, 2005. INTERVENTION(S) In fresh cycles, women used either pituitary desensitization or GnRH antagonists in combination with gonadotropin stimulation protocols before oocyte retrieval. In FET cycles, endometrial development was achieved by oral E(2) and vaginal P after pituitary desensitization. Embryo transfer occurred either on day 3 or on day 5. MAIN OUTCOME MEASURE(S) Implantation and pregnancy rates (PR). RESULT(S) Excluding FET cycles, implantation rates and PRs declined significantly in repeated cycles compared to the initial one. However, women with supernumerary embryos for cryopreservation appeared to produce embryos with higher implantation potential but were excluded from the analysis. When FET cycles were included, there were no significant declines in PRs for at least three repeated cycles. CONCLUSION(S) Embryo cryopreservation stratifies women with high quality embryos from those with low quality embryos who require repeat fresh attempts, resulting in an accelerated decline in observed PRs and implantation rates.
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Affiliation(s)
- Jeff G Wang
- Department of Obstetrics & Gynecology, Division of Reproductive Endocrinology, College of Physicians & Surgeons, Columbia University, New York, New York 10032, USA.
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146
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Mahutte NG, Arici A. Role of gonadotropin-releasing hormone antagonists in poor responders. Fertil Steril 2007; 87:241-9. [PMID: 17113088 DOI: 10.1016/j.fertnstert.2006.07.1457] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2005] [Revised: 04/25/2006] [Accepted: 04/25/2006] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate the role of GnRH antagonists in poor-responder protocols. DESIGN Literature review. CONCLUSION(S) The optimum stimulation protocol for poor responders is unknown. Although many IVF programs currently use GnRH antagonists for poor responders, there have been only four prospective, randomized trials comparing GnRH antagonists to alternate protocols. None of these studies had sufficient power to evaluate a difference in pregnancy rates (PRs), and in all four cases, IVF outcomes were comparable. Nevertheless, interest in the use of GnRH antagonists in poor responders has continued. GnRH antagonists may be associated with simpler stimulation protocols, lower gonadotropin requirements, reduced patient costs, and shorter downtimes between consecutive cycles. However, the greatest advantage of GnRH antagonists may lie in the ability to assess ovarian reserves immediately prior to deciding whether or not to initiate gonadotropin stimulation. The ability to respond to cycle-to-cycle variation in antral follicle counts may allow the optimization of oocyte yield and reduce cycle cancellation rates. It remains to be seen if this approach (initiating gonadotropins only in cycles where an adequate antral follicle count is present) also translates into higher clinical PRs for poor responders.
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Affiliation(s)
- Neal G Mahutte
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Dartmouth Medical School, Lebanon, New Hampshire 03756, USA.
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147
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Orvieto R, Zohav E, Scharf S, Rabinson J, Meltcer S, Anteby EY, Homburg R. The influence of estradiol/follicle and estradiol/oocyte ratios on the outcome of controlled ovarian stimulation for in vitro fertilization. Gynecol Endocrinol 2007; 23:72-5. [PMID: 17454155 DOI: 10.1080/09513590601137137] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE The aim of the study was to evaluate the influence of the ratios of estradiol (E2) to either the number of follicles >14 mm on the day of human chorionic gonadotropin administration (E2/follicle) or the number of oocytes retrieved (E2/oocytes) during controlled ovarian hyperstimulation (COH) with gonadotropin-releasing hormone (GnRH)-agonist (agonist group) and GnRH-antagonist (antagonist group), on the outcome of in vitro fertilization (IVF) cycles. PATIENTS AND METHODS All consecutive women aged <35 years admitted to our IVF unit during a 6-year period with normal to high response to COH were retrospectively studied. Ovarian stimulation characteristics, number of oocytes retrieved, number of embryos transferred and pregnancy rate were assessed. RESULTS Six hundred and ninety consecutive IVF cycles were evaluated, 301 in the agonist group and 389 in the antagonist group. The ratios of E2/follicle and E2/oocyte were significantly higher in the agonist group (p < 0.001 for both). Moreover, while pregnancy rates within E2/oocyte ratio of 100-200 pg/ml were comparable between the agonist and antagonist groups, when E2/oocyte ratios were <100 pg/ml or >200 pg/ml, pregnancy rates were significantly higher in the agonist group. Furthermore, no difference in pregnancy rates was observed within the agonist group between different E2/oocytes ratios, while within the antagonist group, higher pregnancy rates were observed when comparing those with E2/oocyte ratio of 100-200 pg/ml with those with E2/oocyte ratio <100 pg/ml or >200 pg/ml. CONCLUSION While E2/oocyte ratio cannot predict the success of GnRH-agonist protocol, patients undergoing GnRH-antagonist protocol should reach E2/oocyte ratio within the 100-200 pg/ml range in order to achieve the best IVF outcome.
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Affiliation(s)
- Raoul Orvieto
- Department of Obstetrics and Gynecology, Barzilai Medical Center, Ashkelon 78306, Israel.
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148
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Shanbhag S, Aucott L, Bhattacharya S, Hamilton MA, McTavish AR. Interventions for 'poor responders' to controlled ovarian hyperstimulation (COH) in in-vitro fertilisation (IVF). Cochrane Database Syst Rev 2007:CD004379. [PMID: 17253503 DOI: 10.1002/14651858.cd004379.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The success of in-vitro fertilisation (IVF) treatment depends on adequate follicle recruitment by using controlled ovarian stimulation with gonadotrophins. Failure to recruit adequate follicles is called 'poor response'. Various treatment protocols have been proposed that are targeted at this cohort of women, aiming to increase their ovarian response. OBJECTIVES To compare the effectiveness of different treatment interventions in women who have poor response to controlled ovarian hyperstimulation (are poor responders) in the context of in vitro fertilisation. SEARCH STRATEGY We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials (MDSG), the Cochrane Central Register of Controlled trials (CENTRAL) (The Cochrane Library 2003, Issue 1), MEDLINE (1966 to August 2006), EMBASE (1980 to August 2006) and The National Research Register (NRR). The citation lists of relevant publications, review articles, abstracts of scientific meetings and included studies were also searched. The authors were contacted to identify or clarify data that were unclear from the trial reports. SELECTION CRITERIA Only randomised controlled trials (RCTs) comparing one type of intervention versus another for controlled ovarian stimulation of poor responders to a previous IVF treatment, using a standard long protocol were included. DATA COLLECTION AND ANALYSIS Two review authors independently scanned the abstracts, identified relevant papers, assessed inclusion and trial quality and extracted relevant data. Validity was assessed in terms of method of randomisation, completeness of treatment cycle and co-intervention. Where possible, data were pooled for analysis. MAIN RESULTS Nine trials involving six different comparison groups have been included in this review. Only one trial reported live birth rates. Four groups compared the long protocol with another intervention. Only one comparison group (bromocryptine versus long protocol) reported a higher clinical pregnancy rate per cycle, in the bromocryptine arm (OR 5.60, 95% CI 1.40 to 22.47). Two comparison groups showed a lower number of oocytes in the long protocol group (versus stop and gonadotrophin releasing hormone (GnRH) antagonist protocols). However, two comparison groups also showed lower cancellation rates in the long protocol treatment group (versus stop and GnRHa flare-up protocols). None reported any evident difference in the adverse effects. AUTHORS' CONCLUSIONS There is insufficient evidence to support the routine use of any particular intervention either for pituitary downregulation, ovarian stimulation or adjuvant therapy in the management of poor responders to controlled ovarian stimulation in IVF. More robust data from good quality RCTs with relevant outcomes are needed.
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Affiliation(s)
- S Shanbhag
- University of Aberdeen, Assisted Reproduction Unit, Aberdeen Maternity Hospital, Aberdeen, Scotland, UK, AB25 2ZD.
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149
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Garcia-Velasco JA, Coelingh Bennink HJT, Epifanio R, Escudero E, Pellicer A, Simón C. High-dose recombinant LH add-back strategy using high-dose GnRH antagonist is an innovative protocol compared with standard GnRH antagonist. Reprod Biomed Online 2007; 15:280-7. [PMID: 17854525 DOI: 10.1016/s1472-6483(10)60340-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
High daily doses of gonadotrophin-releasing hormone (GnRH) antagonists during the follicular phase of ovarian stimulation were associated with low implantation rates. To test if this occurred because of profound pituitary suppression, the pituitary response was suppressed with a high-dose GnRH antagonist and recombinant LH (rLH) was added back to correct the implantation rate. An open-label, randomized, controlled, prospective clinical study in 60 patients undergoing IVF was performed. GnRH antagonist was initiated on day 6 of stimulation (2 mg/day) together with 375 IU rLH, and maintained until the day of HCG administration. Controls received 0.25 mg/day GnRH antagonist. Fluctuating LH concentrations were present on days 3 and 6 in both groups. This strong fluctuation continued on day 8 and on the day of HCG administration in the control (low-dose) group, where 30% of patients had LH concentrations <1 IU/l on the HCG day. The study (high-dose) group showed stable LH concentrations on day 8 and on the HCG day, with no LH surges. No clinical differences were found between groups. The LH add-back strategy (375 IU/day) rescued the adverse effects that high doses of GnRH imposed on implantation. These results suggest that rLH should be considered during ovarian stimulation with GnRH antagonist.
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150
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Lin YH, Seow KM, Chen HJ, Huang LW, Hwang JL, Tzeng CR. Impact of estradiol patterns in clomiphene citrate/human menopausal gonadotropin/cetrorelix protocol. Gynecol Endocrinol 2007; 23:45-9. [PMID: 17484512 DOI: 10.1080/09513590601137079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
The importance of serum estradiol changes associated with gonadotropin-releasing hormone antagonists is not clear. The purpose of the present study was to analyze the impact of estradiol changes after cetrorelix injection on the outcome of intracytoplasmic sperm injection (ICSI) cycles. This was a prospective observational study. One hundred and thirteen women with male-factor infertility who were undergoing first ICSI cycles were reviewed for this study. Excluding seven cycles with incomplete data, 106 cycles were included in the analysis. The women were stimulated with clomiphene citrate and human menopausal gonadotropin (hMG). Cetrorelix acetate (2.5 mg) was given when the leading follicles reached 14 mm. After cetrorelix administration, serum estradiol rose in 48 cycles (45.3%), plateaued in 26 cycles (24.5%) and dropped in 32 cycles (30.2%). Mean age and day-3 follicle-stimulating hormone, luteinizing hormone and estradiol levels were similar among the three groups. The mean ampoules of hMG used, estradiol levels on the day of human chorionic gonadotropin injection and the clinical outcomes, including numbers of oocytes retrieved and fertilization, implantation and pregnancy rates, were similar in all three groups regardless of the trend of estradiol. In conclusion, estradiol patterns after cetrorelix injection show no correlation with clinical outcome and ovarian reserve, and falling estradiol is not associated with adverse outcome.
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Affiliation(s)
- Yu-Hung Lin
- Department of Obstetrics and Gynecology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
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