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English K, Frise C, Trinder J, Cauldwell M, Simpson M, Adamson D, Elton C, Burns G, Choudhary M, Nathanson M, Robert L, Moore J, O'Brien P, Pundir J. Best practice recommendations for medically assisted reproduction in patients with known cardiovascular disease or at high risk of cardiovascular disease. HUM FERTIL 2024; 27:2278295. [PMID: 38196173 DOI: 10.1080/14647273.2023.2278295] [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: 10/02/2023] [Accepted: 10/02/2023] [Indexed: 01/11/2024]
Abstract
Increasing numbers of people are seeking assisted conception. In people with known cardiac disease or risk factors for cardiac disease, assisted conception may carry increased risks during treatment and any subsequent pregnancy. These risks should be assessed, considered and minimized prior to treatment.
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Affiliation(s)
- Kate English
- Department of Congenital Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Charlotte Frise
- Department of Obstetrics, Queen Charlotte's and Chelsea Hospital, London, UK
| | | | | | | | - Dawn Adamson
- Department of Cardiology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Chris Elton
- Department of Anaesthesia, Leicester Royal Infirmary, Leicester, UK
| | | | - Meenakshi Choudhary
- Newcastle Fertility Centre at Life, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Mike Nathanson
- Department of Anaesthesia, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Leema Robert
- Department of Clinical Genetics, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Jim Moore
- Department of Primary Care, NHS Gloucestershire Clinical Commissioning Group, Brockworth, UK
| | - Pat O'Brien
- Department of Obstetrics, University College London, London, UK
| | - Jyotsna Pundir
- Reproductive Medicine, St Bartholomew's Hospital, London, UK
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Balachandren N, Seshadri S, Yasmin E, Saab W, Gates C, Sayar Z, Cohen H, Webber L. Venous thromboembolism associated with medically assisted reproduction (MAR): British fertility society policy and practice guidance for assessment and prevention. HUM FERTIL 2024; 27:2352387. [PMID: 38804228 DOI: 10.1080/14647273.2024.2352387] [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: 12/27/2023] [Accepted: 04/25/2024] [Indexed: 05/29/2024]
Abstract
The association between Medically Assisted Reproduction (MAR) and thromboembolic complications has been reported widely in multiple published studies. Although venous thromboembolism (VTE) is not thought to be a common complication of MAR, it is associated with high morbidity and is often preventable. Since VTE usually occurs after completion of MAR treatment and is often managed outside of the treating fertility unit, these complications are likely to be underreported and there may be limited awareness of the risks among clinicians. As we continue to see a rise in the total number of MAR treatment cycles, particularly in women over 40 years of age, along with a steady increase in the number of fertility preservation cycles for both medical and social indications, it is likely that we will see an increase in absolute numbers of VTE complications. Currently, there is a lack of management guidance and reporting of VTE events associated with assisted conception treatment. The aim of this guidance is to provide clinicians with information on VTE risk factors, guidance on assessing VTE risk and the best practice recommendations on risk reducing strategies for individuals at risk of VTE undergoing ovarian stimulation and embryo transfer cycles.
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Affiliation(s)
| | | | - Ephia Yasmin
- Reproductive Medicine Unit, University College London Hospital, London, UK
| | - Wael Saab
- The Centre for Reproductive & Genetic Health, London, UK
| | - Carolyn Gates
- Department of Haematology, University College London Hospital, London, UK
| | - Zara Sayar
- Department of Haematology, University College London Hospital, London, UK
- Department of Haematology, Whittington Health NHS Trust, London, UK
| | - Hannah Cohen
- Department of Haematology, University College London Hospital, London, UK
| | - Lisa Webber
- Gynaecology & Reproductive Medicine, Imperial College Healthcare NHS Trust, St Mary's Hospital, London, W2 1NY and Department of Obstetrics & Gynaecology, Singapore General Hospital, Singapore, Singapore
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Guner FC, Ozekinci M, Mendilcioglu II, Kasabali Z. Reproductive Outcomes of Dual Trigger versus hCG Alone in Women Undergoing In Vitro Fertilization with Fresh Embryo Transfer Cycles. Obstet Gynecol Int 2024; 2024:9972437. [PMID: 39015476 PMCID: PMC11251794 DOI: 10.1155/2024/9972437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 06/18/2024] [Accepted: 06/27/2024] [Indexed: 07/18/2024] Open
Abstract
Aim To investigate the effect of the triggering method on the results of fresh embryo transfer in patients who underwent gonadotropin-releasing hormone antagonist cycles. Methods The study was conducted retrospectively at a university-based tertiary reproductive center. The sample consisted of a total of 295 patients, of whom 111 were in the human chorionic gonadotropin (hCG) trigger group and 184 were in the dual trigger group. The main outcome measure of this study was the live birth rate, and secondary outcomes were the implantation rate, clinical pregnancy rate, miscarriage rate, and good-quality embryo rate. Results Patient demographics and baseline characteristics did not significantly differ between the dual and hCG trigger groups. The results also indicated statistically nonsignificant differences between the two groups in terms of the number of oocytes retrieved (p > 0.05), the number of mature oocytes (p > 0.05), and the fertilization rate (p > 0.05). The number of good-quality embryos (p=0.002) was higher in the dual trigger group compared with the hCG trigger group. However, the rates of clinical pregnancy and live births did not significantly differ between the groups (p > 0.05). Conclusions Although the number of total and high-quality embryos obtained was higher in the dual trigger group, there were no significant differences between the two groups in terms of pregnancy outcomes. The fresh embryo transfer yielded similar rates of implantation and live births in both trigger groups.
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Affiliation(s)
- Fatma Ceren Guner
- Department of Obstetrics and GynecologyAkdeniz University, Antalya 07058, Türkiye
| | - Murat Ozekinci
- Department of Obstetrics and GynecologyReproductive Endocrinology and InfertilityAkdeniz University, Antalya 07058, Türkiye
| | | | - Zeliha Kasabali
- IVF UnitDepartment of Obstetrics and GynecologyAkdeniz University, Antalya 07058, Türkiye
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Ranit H, Shmuel H, Ahlad A, Shirley G, Meny H, Tal I, Assaf BM, Chana AL, Yaakov B, Efrat EB, Anat HK. Is there a preferred time interval between gonadotropin-releasing hormone (GnRH) agonist trigger and oocyte retrieval in GnRH antagonist cycles? A retrospective cohort of planned fertility preservation cycles. J Assist Reprod Genet 2024; 41:1531-1538. [PMID: 38492156 PMCID: PMC11224053 DOI: 10.1007/s10815-024-03083-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 03/04/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND The ideal time frame between gonadotropin-releasing hormone (GnRH) agonist (GnRHa) trigger administration and oocyte retrieval in GnRH antagonist cycles has not been well studied. Our goal was to evaluate the effect of this time interval on oocyte yield and oocyte maturation rate in GnRH antagonist cycles designated for non-medical ("planned") oocyte cryopreservation. METHODS We conducted a retrospective cohort study including patients who underwent elective fertility preservation, using the GnRH antagonist protocol and exclusively triggered by GnRH-agonist. We focused on the effect of the trigger-to-retrieval time interval on oocyte yield and maturation rate, while also incorporating age, body mass index (BMI), anti-Müllerian hormone (AMH) levels, basal Follicle-Stimulating Hormone (FSH) levels, as well as the type and dosage of gonadotropin FSH medication. RESULTS 438 cycles were included. Trigger-to-retrieval time interval ranged from 32.03 to 39.92 h. The mean oocyte yield showed no statistically significant difference when comparing retrievals < 36 h (n = 240, 11.86 ± 8.6) to those triggered at ≥ 36 h (n = 198, 12.24 ± 7.73) (P = 0.6). Upon dividing the cohort into four-time quartiles, no significant differences in the number of retrieved oocytes were observed (P = 0.54). Multivariate regression analysis failed to reveal any significant associations between the interval and the aforementioned variables. CONCLUSIONS The GnRHa trigger to oocyte retrieval interval range in our cohort did not significantly affect oocyte yield and maturation rate.
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Affiliation(s)
- Hizkiyahu Ranit
- The IVF unit, Department of Obstetrics and Gynecology, Hadassah Mount Scopus-Hebrew University Medical Center, Jerusalem, 9112001, Israel.
| | - Herzberg Shmuel
- The IVF unit, Department of Obstetrics and Gynecology, Hadassah Ein Kerem-Hebrew University Medical Center, Jerusalem, Israel
| | - Athavale Ahlad
- The IVF unit, Department of Obstetrics and Gynecology, Hadassah Mount Scopus-Hebrew University Medical Center, Jerusalem, 9112001, Israel
| | - Greenbaum Shirley
- The IVF unit, Department of Obstetrics and Gynecology, Hadassah Mount Scopus-Hebrew University Medical Center, Jerusalem, 9112001, Israel
| | - Harari Meny
- Faculty of medicine, Hebrew university of Jerusalem, Jerusalem, Israel
| | - Imbar Tal
- The IVF unit, Department of Obstetrics and Gynecology, Hadassah Ein Kerem-Hebrew University Medical Center, Jerusalem, Israel
- Faculty of medicine, Department of Obstetrics and Gynecology, Hebrew university of Jerusalem, Jerusalem, Israel
| | - Ben-Meir Assaf
- The IVF unit, Department of Obstetrics and Gynecology, Hadassah Ein Kerem-Hebrew University Medical Center, Jerusalem, Israel
- Faculty of medicine, Department of Obstetrics and Gynecology, Hebrew university of Jerusalem, Jerusalem, Israel
| | - Adler Lazarovits Chana
- The IVF unit, Department of Obstetrics and Gynecology, Hadassah Mount Scopus-Hebrew University Medical Center, Jerusalem, 9112001, Israel
| | - Bentov Yaakov
- The IVF unit, Department of Obstetrics and Gynecology, Hadassah Mount Scopus-Hebrew University Medical Center, Jerusalem, 9112001, Israel
| | - Esh-Broder Efrat
- The IVF unit, Department of Obstetrics and Gynecology, Hadassah Mount Scopus-Hebrew University Medical Center, Jerusalem, 9112001, Israel
- Faculty of medicine, Department of Obstetrics and Gynecology, Hebrew university of Jerusalem, Jerusalem, Israel
| | - Hershko Klement Anat
- The IVF unit, Department of Obstetrics and Gynecology, Hadassah Mount Scopus-Hebrew University Medical Center, Jerusalem, 9112001, Israel
- Faculty of medicine, Department of Obstetrics and Gynecology, Hebrew university of Jerusalem, Jerusalem, Israel
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Avraham S, Youngster M, Yerushalmi G, Belov Y, Gat I, Kedem A, Yaakov O, Gidoni Y, Barkat J, Baruchin O, Hourvitz A. Follicular challenge test to predict suboptimal response to gonadotropin releasing hormone agonist trigger in elective oocyte cryopreservation cycles. Sci Rep 2024; 14:6204. [PMID: 38485977 PMCID: PMC10940571 DOI: 10.1038/s41598-024-56418-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 03/06/2024] [Indexed: 03/18/2024] Open
Abstract
This prospective study aimed to test the ability of follicular GnRH agonist challenge test (FACT) to predict suboptimal response to GnRH agonist trigger, assessed by LH levels post ovulation trigger in non-medical oocyte cryopreservation program. The study included 91 women that underwent non-medical fertility preservation. On day two to menstrual cycle, blood tests were drawn (basal Estradiol, basal FSH, basal LH, Progesterone) and ultrasound (US) was performed. On that evening, the women were instructed to inject 0.2 mg GnRH agonist (FACT) and arrive for repeated blood workup 10-12 h later in the next morning, followed by a flexible antagonist protocol. LH levels on the morning after ovulation trigger were compared to FACT LH levels. The results demonstrated that LH levels following agonist ovulation trigger below 15IU/L occurred in 1.09% of cycles and were predicted by FACT, r = 0.57, p < 0.001. ROC analysis demonstrated that FACT LH > 42.70 IU/L would predict LH post trigger of more than 30 IU/L with 75% sensitivity and 70% specificity, AUC = 0.81. LH levels post trigger also displayed significant positive correlation to basal FSH (r = 0.35, p = 0.002) and basal LH (r = 0.54, p < 0.001). LH levels post ovulation trigger were not associated with total oocytes number or maturity rate. The strongest correlation to the number of frozen oocytes was progesterone levels post agonist trigger (r = 0.746, p < 0.001). We concluded that suboptimal response to agonist trigger, as assessed by post trigger LH levels was a rare event. FACT could serve as an adjunct pre-trigger, intracycle tool to predict adequate LH levels elevation after agonist ovulation trigger. Future studies should focus on optimization of agonist trigger efficacy assessment and prediction, especially in high responders.
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Affiliation(s)
- Sarit Avraham
- IVF Unit, Department of Obstetrics and Gynecology, Shamir Medical Centre, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tzrifin, Israel.
| | - Michal Youngster
- IVF Unit, Department of Obstetrics and Gynecology, Shamir Medical Centre, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tzrifin, Israel
| | - Gil Yerushalmi
- IVF Unit, Department of Obstetrics and Gynecology, Shamir Medical Centre, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tzrifin, Israel
| | - Yekaterina Belov
- Lis Hospital for Women, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Itai Gat
- IVF Unit, Department of Obstetrics and Gynecology, Shamir Medical Centre, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tzrifin, Israel
| | - Alon Kedem
- IVF Unit, Department of Obstetrics and Gynecology, Shamir Medical Centre, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tzrifin, Israel
| | - Odelia Yaakov
- IVF Unit, Department of Obstetrics and Gynecology, Shamir Medical Centre, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tzrifin, Israel
| | - Yariv Gidoni
- IVF Unit, Department of Obstetrics and Gynecology, Shamir Medical Centre, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tzrifin, Israel
| | - Jonathan Barkat
- IVF Unit, Department of Obstetrics and Gynecology, Shamir Medical Centre, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tzrifin, Israel
| | - Ohad Baruchin
- IVF Unit, Department of Obstetrics and Gynecology, Shamir Medical Centre, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tzrifin, Israel
| | - Ariel Hourvitz
- IVF Unit, Department of Obstetrics and Gynecology, Shamir Medical Centre, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tzrifin, Israel
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Aziz NA, Ibrahim A, Ramli R, Yaacob N, Rahman SNA, Ismail EHE, Omar AA. Comparison between hCG and GnRH Agonist for Ovulation Trigger in GnRH Antagonist In-Vitro Fertilization Cycles in a Tertiary Hospital in Malaysia: An observational study. JBRA Assist Reprod 2024; 28:21-26. [PMID: 38224580 PMCID: PMC10936917 DOI: 10.5935/1518-0557.20230066] [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: 12/25/2022] [Accepted: 07/31/2023] [Indexed: 01/17/2024] Open
Abstract
OBJECTIVE hCG is commonly used as an ovulation trigger in IVF. Its usage is associated with OHSS. GnRH agonist is an alternative to hCG and is associated with reduced incidence of OHSS. This study compared the cycle outcomes of GnRH agonists with hCG as an ovulation trigger in IVF cycles. METHODS The medical notes of 209 IVF cycles receiving GnRH agonist and hCG as ovulation trigger over 18 months were reviewed in this retrospective study. The number and quality of mature oocytes, the number and quality of embryos, pregnancy rates, and outcomes were compared using Independent T-test or One-way ANOVA for normal distribution. The Mann-Whitney test or Kruskal-Wallis test was used for not normally distributed. p<0.05 was considered statistically significant. RESULTS The cycle outcomes of 107 GnRH agonist-trigger and 102 hCG-trigger were compared. The MII oocytes retrieved and 2PN count was significantly higher in the GnRH agonist trigger group (p<0.001). Clinical pregnancy rate and ongoing pregnancy were higher in the GnRH agonist trigger group but were not statistically significant. The GnRH agonist trigger group was associated with low OHSS than the hCG trigger group (n=2(1.9%) and n=12(11.8%) respectively, p=0.004). CONCLUSION GnRH agonist trigger is an option as a final maturation trigger in high-responder women undergoing IVF or ICSI cycles.
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Affiliation(s)
- Nor Azimah Aziz
- Department of Obstetrics and Gynaecology, School of Medical
Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
- Department of Obstetrics and Gyneaecology, Hospital Universiti
Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
- Department of Obstetrics and Gynaecology, Hospital Sultanah Nur
Zahirah, Kuala Terengganu, Terengganu, Malaysia
| | - Adibah Ibrahim
- Department of Obstetrics and Gynaecology, School of Medical
Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
- Department of Obstetrics and Gyneaecology, Hospital Universiti
Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Roziana Ramli
- Department of Obstetrics and Gynaecology, Hospital Sultanah Nur
Zahirah, Kuala Terengganu, Terengganu, Malaysia
| | - Nasuha Yaacob
- Department of Obstetrics and Gynaecology, Hospital Sultanah Nur
Zahirah, Kuala Terengganu, Terengganu, Malaysia
| | - Siti Nabillah Abdul Rahman
- Department of Obstetrics and Gynaecology, Hospital Sultanah Nur
Zahirah, Kuala Terengganu, Terengganu, Malaysia
| | - Engku Husna Engku Ismail
- Department of Obstetrics and Gynaecology, School of Medical
Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
- Department of Obstetrics and Gyneaecology, Hospital Universiti
Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Ahmad Akram Omar
- Department of Obstetrics and Gynaecology, School of Medical
Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
- Department of Obstetrics and Gyneaecology, Hospital Universiti
Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
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Wang Q, Wan Q, Li T, Wang X, Hu Y, Zhong Z, Pu K, Ding Y, Tang X. Effect of GnRH agonist trigger with or without low-dose hCG on reproductive outcomes for PCOS women with freeze-all strategy: a propensity score matching study. Arch Gynecol Obstet 2024; 309:679-688. [PMID: 38032411 DOI: 10.1007/s00404-023-07285-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/31/2023] [Indexed: 12/01/2023]
Abstract
PURPOSE This study aimed to compare the effect of gonadotropin-releasing hormone agonist (GnRHa) trigger alone versus dual trigger comprising GnRHa and low-dose human chorionic gonadotropin (hCG) on reproductive outcomes in patients with polycystic ovary syndrome (PCOS) who received the freeze-all strategy. METHODS A total of 615 cycles were included in this retrospective cohort study. Propensity score matching (PSM) was performed to control potential confounding factors between GnRHa-trigger group (0.2 mg GnRHa) and dual-trigger group (0.2 mg GnRHa plus 1000/2000 IU hCG) in a 1:1 ratio. Multivariate logistic regression was applied to estimate the association between trigger methods and reproductive outcomes. RESULTS After PSM, patients with dual trigger (n = 176) had more oocytes retrieved, mature oocytes, and 2PN embryos compared to that with GnRHa trigger alone. However, the oocytes maturation rate, normal fertilization rate, and frozen embryos between the two groups were not statistically different. The incidence of ovarian hyperstimulation syndrome (OHSS) (14.8% vs. 2.8%, P < 0.001) and moderate/severe OHSS (11.4% vs. 1.7%, P < 0.001) were significantly higher in dual-trigger group than in GnRHa-alone group. Logistic regression analysis showed the adjusted odds ratio of dual trigger was 5.971 (95% confidence interval 2.201-16.198, P < 0.001) for OHSS. The pregnancy and single neonatal outcomes were comparable between the two groups (P > 0.05). CONCLUSION For PCOS women with freeze-all strategy, GnRHa trigger alone decreased the risk of OHSS without damaging oocyte maturation and achieved satisfactory pregnancy outcomes.
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Affiliation(s)
- Qiaofeng Wang
- Department of Epidemiology, School of Public Health, Chongqing Medical University, Chongqing, China
- Chongqing University Three Gorges Hospital, Wanzhou, Chongqing, China
| | - Qi Wan
- Department of Gynecology and Obstetrics, West China Second Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Tian Li
- Department of Reproductive Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xuejiao Wang
- Department of Reproductive Center, Chengdu Jinjiang Hospital for Women's and Children's Health, Chengdu, China
| | - Yuling Hu
- Department of Reproductive Center, Chengdu Jinjiang Hospital for Women's and Children's Health, Chengdu, China
| | - Zhaohui Zhong
- Department of Epidemiology, School of Public Health, Chongqing Medical University, Chongqing, China
| | - Kexue Pu
- Chongqing Engineering Research Center for Clinical Big Data and Drug Evaluation, College of Medical Informatics, Chongqing Medical University, Chongqing, China
| | - Yubin Ding
- Joint International Research Laboratory of Reproduction and Development of the Ministry of Education of China, School of Public Health, Chongqing Medical University, Chongqing, China.
- Department of Obstetrics and Gynecology, Women and Children's Hospital of Chongqing Medical University, Chongqing Medical University, Chongqing, China.
| | - Xiaojun Tang
- Department of Epidemiology, School of Public Health, Chongqing Medical University, Chongqing, China.
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Puthur SJ, Tracey S, Gould D, Fitzgerald CT. DuoStim protocol- a novel fertility preservation strategy for female oncology patients. HUM FERTIL 2023; 26:1361-1367. [PMID: 36999567 DOI: 10.1080/14647273.2023.2193907] [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: 09/14/2021] [Accepted: 12/06/2022] [Indexed: 04/01/2023]
Abstract
Fertility loss is one of the primary concerns among female oncology patients of childbearing age about to undergo gonadotoxic therapy. Currently, controlled ovarian stimulation (COS) followed by oocyte or embryo cryopreservation is the only technique of fertility preservation (FP) endorsed by the American Society of Clinical Oncology. This retrospective cohort study aims to evaluate the effectiveness of a modified 'DuoStim' COS protocol in 36 female oncology patients at an FP clinic at St Mary's Hospital Reproductive Medicine Unit (Manchester, UK). Patients underwent two consecutive cycles of COS and outcomes assessed included total oocyte yield, mature oocytes of metaphase stage II, side effects of ovarian stimulation such as ovarian hyperstimulation syndrome (OHSS) and delays to planned cancer therapy. Details of patient outcomes were determined by the review of patient medical records. Results of the study showed that this novel protocol increased oocyte yield by two-fold without delaying oncology treatment. Medical records confirmed that none of the 36 patients developed OHSS or experienced any delays in their cancer therapy. We conclude that the results of this study are encouraging and support DuoStim protocol as an effective strategy for FP in female FP patients.
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Affiliation(s)
- Sarah J Puthur
- St Mary's Hospital Reproductive Medicine Unit, Manchester, UK
| | - Susan Tracey
- St Mary's Hospital Reproductive Medicine Unit, Manchester, UK
| | - Della Gould
- St Mary's Hospital Reproductive Medicine Unit, Manchester, UK
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9
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Yan MH, Sun ZG, Song JY. Dual trigger for final oocyte maturation in expected normal responders with a high immature oocyte rate: a randomized controlled trial. Front Med (Lausanne) 2023; 10:1254982. [PMID: 37869157 PMCID: PMC10585044 DOI: 10.3389/fmed.2023.1254982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 09/22/2023] [Indexed: 10/24/2023] Open
Abstract
Objective To evaluate whether dual trigger could improve reproductive outcomes in women with low oocyte maturation rates compare to human chorionic gonadotropin (hCG) trigger. Methods This study included expected normal ovarian responders younger than 40 years old whose immature oocyte rate in the previous cycle was more than 50% at the reproductive center from July 2021 to November 2022. A total of 73 patients were enrolled at trigger, including 34 in the hCG trigger group and 39 in the dual trigger group (co-administration of gonadotrophin releasing hormone (GnRH) agonist and hCG, 40 and 34 h prior to oocyte retrieval, respectively). The primary outcome was oocyte maturation rate. Results There was no significant difference in the number of oocytes retrieved between the two study groups, but the oocyte maturation rate was higher in dual trigger group (84.0% [14.0%] vs. 55.5% [19.8%], p < 0.001). Moreover, there were also higher cumulative pregnancy rate (69.4% vs. 40.0%, p = 0.035) and cumulative live birth rate (66.7% vs. 36.0%, p = 0.022) in dual trigger group. Conclusion For normal responders with low oocyte maturation rates, the dual trigger may be more effective than the conventional hCG trigger. Clinical trial registration ClinicalTrials.gov, identifier ChiCTR2100049292.
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Affiliation(s)
- Meng-Han Yan
- The First Clinical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Zhen-Gao Sun
- The First Clinical College, Shandong University of Traditional Chinese Medicine, Jinan, China
- Reproductive Center of Integrated Medicine, The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Jing-Yan Song
- The First Clinical College, Shandong University of Traditional Chinese Medicine, Jinan, China
- Reproductive Center of Integrated Medicine, The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
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10
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Ip PNP, Mak JSM, Law TSM, Ng K, Chung JPW. A reappraisal of ovarian stimulation strategies used in assisted reproductive technology. HUM FERTIL 2023; 26:824-844. [PMID: 37980170 DOI: 10.1080/14647273.2023.2261627] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 07/10/2023] [Indexed: 11/20/2023]
Abstract
Ovarian stimulation is a fundamental step in assisted reproductive technology (ART) with the intention of inducing ovarian follicle development prior to timed intercourse or intra-uterine insemination and facilitating the retrieval of multiple oocytes during a single in vitro fertilization (IVF) cycle. The basis of ovarian stimulation includes the administration of exogenous gonadotropins, with or without pre-treatment with oral hormonal therapy. Gonadotropin-releasing hormone agonist or antagonist is given in addition to the gonadotropins to prevent a premature rise of endogenous luteinizing hormone that would in turn lead to premature ovulation. With the advancement in technology, various stimulation protocols have been devised to cater for different patient needs. However, ovarian hyperstimulation syndrome and its serious complications may occur following ovarian stimulation. It is also evident that suboptimal ovarian stimulation strategies may have a negative impact on oogenesis, embryo quality, endometrial receptivity, and reproductive outcomes over recent years. This review describes the various forms of pre-treatment for ovarian stimulation and stimulation protocols, and aims to provide clinicians with the latest available evidence.
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Affiliation(s)
- Patricia N P Ip
- Assisted Reproductive Technology, Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Jennifer S M Mak
- Assisted Reproductive Technology, Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Tracy S M Law
- Assisted Reproductive Technology, Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Karen Ng
- Assisted Reproductive Technology, Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Jacqueline P W Chung
- Assisted Reproductive Technology, Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong SAR, China
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11
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Jin H, Yang H, Zheng J, Zhou J, Yu R. Post-trigger luteinizing hormone concentration to positively predict oocyte yield in the antagonist protocol and its association with genetic variants of LHCGR. J Ovarian Res 2023; 16:189. [PMID: 37691102 PMCID: PMC10494325 DOI: 10.1186/s13048-023-01271-6] [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: 04/10/2023] [Accepted: 08/30/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND The concentration of human chorionic gonadotropin (hCG)/ luteinizing hormone (LH) after triggering is generally accepted as a predictor of the normal ovarian response to the trigger, but few studies have explored the distribution model of concentration and its impact on oocyte yield. Genetic variations in LHCGR, known as a receptor for hCG and LH, also play a role in oocyte maturation and retrieval. The objective of the study was to investigate the impact of concentrations of hCG/LH after triggering on oocyte yield and its association with genetic variants of LHCGR. METHODS A retrospective cohort study including 372 antagonist IVF cycles, in which 205 received the recombinant hCG trigger and 167 received the gonadotropin-releasing hormone agonist (GnRH-a) trigger, was conducted. The post-trigger concentrations of hCG/LH and the LHCGR N312S (rs2293275) genotype were evaluated in patients to analyse the impact of these factors on oocyte yield. RESULTS The oocyte retrieval rate (ORR) increased significantly among the low-, medium- and high-hCG-concentration groups (0.91 ± 0.25, 0.99 ± 0.23 and 1.08 ± 0.19, P < 0.001) and among the low-, medium- and high-LH-concentration groups (0.80 ± 0.29, 0.95 ± 0.21 and 1.07 ± 0.19, P < 0.001). The Pearson correlation coefficient between the post-trigger hCG concentration and ORR was 0.242 (P < 0.001), and that between the LH concentration and ORR was 0.454 (P < 0.001). After adjustment for confounding factors, high post-trigger LH concentrations remained associated with the significantly higher ORRs (adjusted R2 = 0.541, P < 0.001). Patients with the AG genotype of LHCGR N312S were more likely to have low post-trigger LH concentrations (46.10 IU/L versus 60.91 IU/L, P < 0.001) and a significantly lower ORR (0.85 versus 0.96, P = 0.042) than patients with the GG genotype after the GnRH-a trigger. CONCLUSIONS The post-trigger LH concentration can positively predict oocyte yield in antagonist IVF cycles, and patients with the AG genotype of LHCGR rs2293275 could have a suboptimal oocyte yield using the GnRH-a trigger.
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Affiliation(s)
- Hao Jin
- The Urological Surgical Department, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Haiyan Yang
- The Reproductive Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China, No. 96, Fuxue Road, Lucheng District
| | - Jiujia Zheng
- The Reproductive Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China, No. 96, Fuxue Road, Lucheng District
| | - Jiechun Zhou
- The Reproductive Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China, No. 96, Fuxue Road, Lucheng District
| | - Rong Yu
- The Reproductive Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China, No. 96, Fuxue Road, Lucheng District.
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12
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Kotlyar AM, Seifer DB. Women with PCOS who undergo IVF: a comprehensive review of therapeutic strategies for successful outcomes. Reprod Biol Endocrinol 2023; 21:70. [PMID: 37528417 PMCID: PMC10391774 DOI: 10.1186/s12958-023-01120-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 07/15/2023] [Indexed: 08/03/2023] Open
Abstract
Polycystic ovarian syndrome (PCOS) is a widespread syndrome that poses unique challenges and constraints to the field of assisted reproductive technology. This condition is the most common cause of anovulation among infertile couples. Debate exists over the best therapeutic course of action when patients with PCOS proceed to IVF. In this review, we evaluate the best-performing and safest methods of IVF preparation, ovarian stimulation, trigger method for maturation of stimulated egg growth, and planning for embryo transfer. Pre-IVF considerations include being aware of individual AMH and vitamin D levels as well as BMI prior to selecting an ovarian stimulation protocol. Numerous supplements such as myo-inositol complement the benefits of lifestyle change and may enhance IVF performance including oocyte yield and pregnancy rate. Concerning stimulation protocols, antagonist cycles with the judicious use of GnRH agonist trigger, pre-treatment with metformin and vitamin D repletion may help mitigate the accompanied risk of ovarian hyperstimulation syndrome (OHSS). Following ovarian stimulation, PCOS patients typically undergo programmed frozen embryo transfer (FET) cycles which are more conducive for women with irregular cycles, but likely carry a higher risk of hypertensive disorders of pregnancy. However, newer stimulated FET protocols using Letrozole may offer improved outcomes. Overall, patients with PCOS require careful individual tailoring of their IVF cycle to achieve optimal results.
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Affiliation(s)
- Alexander M Kotlyar
- Genesis Fertility/Maimonides Medical Center, Brooklyn, NY, USA.
- Downstate Medical Center School of Medicine, State University of New York, Brooklyn, NY, USA.
| | - David B Seifer
- Section of Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, Yale University, New Haven, CT, USA
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Sánchez MF, Larsson P, Serrano MF, Bosch E, Velasco JAG, López ES, Mannaerts B. Live birth rates following individualized dosing algorithm of follitropin delta in a long GnRH agonist protocol. Reprod Biol Endocrinol 2023; 21:45. [PMID: 37194068 DOI: 10.1186/s12958-023-01090-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 04/06/2023] [Indexed: 05/18/2023] Open
Abstract
PURPOSE To explore the efficacy and safety of individualized follitropin delta dosing, based on serum anti-Müllerian hormone (AMH) concentration and bodyweight, in a long gonadotropin-releasing hormone (GnRH) agonist protocol. METHODS Clinical outcomes after one treatment cycle are reported in women with AMH: 5-35 pmol/L. Oocytes were inseminated by intracytoplasmic sperm injection, blastocyst transfer was on Day 5 and remaining blastocysts were cryopreserved. Data collection included live births and neonatal health follow-up for all fresh/frozen transfers performed within one year after treatment allocation. RESULTS In total, 104 women started stimulation, of whom 101 had oocyte recovery and 92 had blastocyst transfer. The average daily dose of follitropin delta was 11.0 ± 1.6 µg and the duration of stimulation was 10.3 ± 1.6 days. The mean number of oocytes was 12.5 ± 6.4, the mean number of blastocysts was 5.1 ± 3.4, and 85% had at least one good-quality blastocyst. Following mostly single blastocyst transfer (95%), the ongoing pregnancy rate was 43%, the live-birth rate was 43%, and the cumulative live-birth rate was 58% per started stimulation. There were 6 cases of early OHSS (5.8%) graded as mild (n = 3) and moderate (n = 3) and 6 cases of late OHSS (5.8%) graded as moderate (n = 3) and severe (n = 3). CONCLUSION In this first evaluation of the individualized follitropin delta dosing in a long GnRH agonist protocol, the cumulative live-birth rate was high. A randomized trial comparing follitropin delta in a long GnRH agonist protocol versus in a GnRH antagonist protocol should provide further insight into the efficacy and safety of this treatment option. TRIAL REGISTRATION NUMBER NCT03564509; June 21, 2018.
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Affiliation(s)
- Manuel Fernández Sánchez
- IVI-RMA Seville, Avenida Americo Vespucio 19, Seville, ES-41092, Spain.
- Department of Surgery, Universidad de Sevilla, Seville, ES-41004, Spain.
- Department of Molecular Biology and Biochemical Engineering, Universidad Pablo de Olavide, Seville, 41013, ES, Spain.
- Fundacion IVI, Instituto Investigación Sanitaria La Fe, Valencia, ES-46026, Spain.
| | - Per Larsson
- Global Biometrics, Ferring Pharmaceuticals A/S, Amager Strandvej 405, Kastrup, 2770, Denmark
| | - Marcos Ferrando Serrano
- Fundacion IVI, Instituto Investigación Sanitaria La Fe, Valencia, ES-46026, Spain
- IVI Bilbao, Bilbao, Valencia, Spain
| | - Ernesto Bosch
- Fundacion IVI, Instituto Investigación Sanitaria La Fe, Valencia, ES-46026, Spain
- IVI Valencia, Valencia, Spain
| | - Juan Antonio García Velasco
- Fundacion IVI, Instituto Investigación Sanitaria La Fe, Valencia, ES-46026, Spain
- IVI-RMA Madrid, Madrid, Spain
| | - Esther Santamaría López
- IVI-RMA Seville, Avenida Americo Vespucio 19, Seville, ES-41092, Spain
- Fundacion IVI, Instituto Investigación Sanitaria La Fe, Valencia, ES-46026, Spain
| | - Bernadette Mannaerts
- Reproductive Medicine & Maternal Health, Ferring Pharmaceuticals A/S, Amager Strandvej 405, Kastrup, 2770, Denmark
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14
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Zheng D, Shi Y, Wang Y, Li R, Long X, Qiao J. The Incidence of Moderate and Severe Ovarian Hyperstimulation Syndrome in Hospitalized Patients in China. HEALTH DATA SCIENCE 2023; 3:0009. [PMID: 38487201 PMCID: PMC10880172 DOI: 10.34133/hds.0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 02/07/2023] [Indexed: 03/17/2024]
Abstract
Background Ovarian hyperstimulation syndrome (OHSS) occurs in women receiving fertility treatments. Moderate and severe OHSS cases are required to be admitted to hospital for treatment. The incidence of moderate and severe OHSS and the characteristics of these cases are unknown in China. We aimed to assess the incidence of moderate and severe OHSS in national databases from China between 2013 and 2017. Methods We extracted moderate and severe OHSS cases from the Hospital Quality Monitoring System, the nationwide inpatient data collection system. We used ovum pick-up (OPUbaidu) cycle data from the annual report of China's National Health Commission, developed on the basis of OPU data collected by National ART Management Information System. Overall incidence of moderate and severe OHSS (women aged 20 to 50 years) and year-specific incidence by each calendar year in China were calculated. We also investigated the age distribution in OHSS and OHSS with different comorbidities. Results We extracted 18,022 eligible patients with moderate or severe OHSS and 1,581,703 OPU cycles. The overall incidence of moderate and severe OHSS between 2013 and 2017 was 1.14%. The year-specific moderate and severe OHSS incidence was 1.1% in 2013, 1.4% in 2014, 1.4% in 2015, 1.1% in 2016, 0.9% in 2017, respectively. Women aged 26 to 30 years accounted for 48.4% of OHSS cases, followed by women aged 31 to 35 years (30%) and 20 to 25 years (14.2%). The age distribution pattern was consistent across OHSS with different comorbidities. Conclusions This study reported the incidence of moderate and severe OHSS in China using nationwide data for the first time. Our findings support that women aged under 35 years receiving assisted reproductive technology need more attention than other age groups in terms of OHSS risk control.
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Affiliation(s)
- Danni Zheng
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
- Beijing Advanced Innovation Center for Genomics, Beijing 100871, China
- Peking-Tsinghua Center for Life Sciences, Peking University, Beijing 100871, China
| | - Ying Shi
- China Standard Medical Information Research Center, Shenzhen, China
| | - Yuanyuan Wang
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
- Beijing Advanced Innovation Center for Genomics, Beijing 100871, China
- Peking-Tsinghua Center for Life Sciences, Peking University, Beijing 100871, China
| | - Rong Li
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
- Beijing Advanced Innovation Center for Genomics, Beijing 100871, China
- Peking-Tsinghua Center for Life Sciences, Peking University, Beijing 100871, China
| | - Xiaoyu Long
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
- Beijing Advanced Innovation Center for Genomics, Beijing 100871, China
- Peking-Tsinghua Center for Life Sciences, Peking University, Beijing 100871, China
| | - Jie Qiao
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
- Beijing Advanced Innovation Center for Genomics, Beijing 100871, China
- Peking-Tsinghua Center for Life Sciences, Peking University, Beijing 100871, China
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15
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Kahraman S, Sahin Y, Duzguner INB, Duzguner S. Factors influencing the number of mature oocytes and cryopreservable blastocysts in hyperresponder patients triggered with a GnRH analog. J Assist Reprod Genet 2023; 40:407-416. [PMID: 36600075 PMCID: PMC9935779 DOI: 10.1007/s10815-022-02702-x] [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: 01/26/2022] [Accepted: 12/19/2022] [Indexed: 01/06/2023] Open
Abstract
PURPOSE This study aimed to investigate which patient and cycle characteristics may affect the number of mature oocytes and cryopreservable blastocysts in the GnRH analog trigger cases. METHODS This was a retrospective cohort study of 2749 GnRHa trigger cycles in patients at risk of OHSS, including a group of PGT patients, between 2011 and 2020 at Istanbul Memorial Hospital, ART and Reproductive Genetics Center. Patient and cycle characteristics were evaluated using the Generalized Linear Mixed Model (GLMM). The number of mature oocytes and the number of cryopreservable blastocysts were evaluated. RESULTS A one-unit increase in female age, daily gonadotropin dose, E2 level on day 2, and LH level on trigger day significantly decreased the number of mature oocytes retrieved (p < 0.001) and the number of cryopreservable blastocysts as p < 0.001, p < 0.001, p < 0.001, and p = 0.003, respectively. The duration of GnRH antagonist use also decreased the number of mature oocytes retrieved (p < 0.001) but not the number of cryopreservable blastocysts. CONCLUSION The GLMM used in our study showed that a one-unit increase in female age, daily gonadotropin dose, E2 level on day 2, and LH level on trigger day significantly decreased the number of mature oocytes retrieved and the number of cryopreservable blastocysts.
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Affiliation(s)
- Semra Kahraman
- Assisted Reproductive Technologies and Reproductive Genetics Center, Istanbul Memorial Hospital, Piyalepasa Bulvari, Sisli, Istanbul, 34384, Turkey.
| | - Yucel Sahin
- Assisted Reproductive Technologies and Reproductive Genetics Center, Istanbul Memorial Hospital, Piyalepasa Bulvari, Sisli, Istanbul, 34384, Turkey
| | - Ipek Nur Balin Duzguner
- Assisted Reproductive Technologies and Reproductive Genetics Center, Istanbul Memorial Hospital, Piyalepasa Bulvari, Sisli, Istanbul, 34384, Turkey
| | - Soner Duzguner
- Assisted Reproductive Technologies and Reproductive Genetics Center, Istanbul Memorial Hospital, Piyalepasa Bulvari, Sisli, Istanbul, 34384, Turkey
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16
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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.
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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
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[Becoming requesting couples after their registration in oocyte donation]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2023; 51:53-59. [PMID: 36336287 DOI: 10.1016/j.gofs.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/19/2022] [Accepted: 10/30/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Many studies have investigated the causes of discontinuation during intraconjugal medically assisted procreation. However, there are currently very few data justifying the causes of discontinuation during the oocyte donation program. The main objective of this study is to determine the causes of discontinuation in oocyte donation and their respective frequency, excluding live births by oocyte donation in our center. METHODS This is an observational, retrospective, single-center study focused on receiving or requesting couples who stopped their oocyte donation program between January 1, 2005 and April 29, 2021. A total of 390 couples were included in the study. RESULTS Of the 390 couples included, 306 couples or nearly 80%, left our oocyte donation program without obtaining a live birth through this method. The three most frequent reasons for discontinuation were: failure of several oocyte donations (18%), desire of the couples to voluntarily discontinue their care (15%) and separation (14%). Finally, 84 couples obtained at least one live birth by oocyte donation in our center. In addition, 38 women conceived spontaneously and 33 couples benefited from an oocyte donation abroad. CONCLUSIONS The most common reason for discontinuation in oocyte donation program, excluding live births by oocyte donation in our center, is failure after several oocyte donations. However, 40% of the couples in the study obtained at least one live birth.
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18
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Li XF, Wang QF, He QQ, Wang XJ, LV XY, Tang XJ, Zhong ZH, Ding YB, Wan Q. Low LH level does not indicate poor IVF cycle outcomes with GnRh-a single trigger: a retrospective analysis. BMC Pregnancy Childbirth 2022; 22:951. [PMID: 36539727 PMCID: PMC9764504 DOI: 10.1186/s12884-022-05251-4] [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: 07/29/2022] [Accepted: 11/25/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To compare the in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) cycle outcomes between patients with low and normal serum luteinizing hormone (LH) levels on the day after a gonadotropin-releasing hormone agonist (GnRH-a) single trigger. We further investigated the efficacy of human chorionic gonadotropin (hCG) retrigger on IVF cycle outcomes in patients with low LH levels after GnRH-a single trigger. METHODS We retrospectively analyzed 957 infertile patients (tubal factor, ovulation disorders, male sperm factor, or unexplained infertility) who were treated with IVF/ICSI at the Chengdu Xinan Gynecology Hospital from July 2017 to December 2020. Patients received sufficient GnRH-a single trigger were divided into two groups based on the serum LH levels on the next day of trigger: normal serum LH levels (≥ 10 mIU/mL) group (control group, n = 906) and low LH levels (< 10 mIU/mL) group (experimental group, n = 51). And the efficacy of hCG retrigger on IVF/ICSI cycle outcomes in 10 patients with low LH levels after GnRH-a single trigger. RESULTS There were no significant differences in IVF/ICSI cycle outcomes, including egg yield, two pronuclei fertilization rate, excellent embryo rate, or live birth rate of frozen-thawed embryos between patients with low and normal LH levels after GnRH-a trigger. It showed significantly higher risk of ovarian hyperstimulation syndrome in the group of low LH levels [ 0.7%(1/137) vs. 8.5%(4/47), P = 0.016] compared with the group of normal LH levels who received GnRH-a single trigger. The hCG retrigger had no obvious efficacy on cycle outcomes in patients with low LH levels, including oocytes retrieved, fertilization rate, embryo conditions, and live birth rate of frozen-thawed cycles. CONCLUSION The IVF/ICSI cycle outcomes of patients with low LH levels on the day after GnRH-a administration were similar to those of patients with normal LH levels. Blood LH test might not be required on the day following the trigger. The hCG retrigger did not have any effect on the cycle outcomes, suggesting that immediate retriggering with hCG was unnecessary.
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Affiliation(s)
- Xue-Fei Li
- The Reproductive Center, Chengdu Jinjiang Hospital for Women’s and Children’s Health, Sichuan 610041 Chengdu, China
| | - Qiao-Feng Wang
- grid.203458.80000 0000 8653 0555Joint International Research Laboratory of Reproduction and Development of the Ministry of Education of China, School of Public Health, Chongqing Medical University, 400016 Chongqing, China ,grid.203458.80000 0000 8653 0555Department of Epidemiology, School of Public Health, Chongqing Medical University, Chongqing, China ,grid.488412.3Department of Obstetrics and Gynecology, Women and Children’s Hospital of Chongqing Medical University, 401147 Chongqing, China
| | - Qi-Qi He
- The Reproductive Center, Chengdu Jinjiang Hospital for Women’s and Children’s Health, Sichuan 610041 Chengdu, China
| | - Xue-Jiao Wang
- The Reproductive Center, Chengdu Jinjiang Hospital for Women’s and Children’s Health, Sichuan 610041 Chengdu, China
| | - Xing-Yu LV
- The Reproductive Center, Chengdu Jinjiang Hospital for Women’s and Children’s Health, Sichuan 610041 Chengdu, China
| | - Xiao-Jun Tang
- grid.203458.80000 0000 8653 0555Joint International Research Laboratory of Reproduction and Development of the Ministry of Education of China, School of Public Health, Chongqing Medical University, 400016 Chongqing, China ,grid.203458.80000 0000 8653 0555Department of Epidemiology, School of Public Health, Chongqing Medical University, Chongqing, China
| | - Zhao-Hui Zhong
- grid.203458.80000 0000 8653 0555Joint International Research Laboratory of Reproduction and Development of the Ministry of Education of China, School of Public Health, Chongqing Medical University, 400016 Chongqing, China ,grid.203458.80000 0000 8653 0555Department of Epidemiology, School of Public Health, Chongqing Medical University, Chongqing, China
| | - Yu-Bin Ding
- grid.488412.3Department of Obstetrics and Gynecology, Women and Children’s Hospital of Chongqing Medical University, 401147 Chongqing, China
| | - Qi Wan
- The Reproductive Center, Chengdu Jinjiang Hospital for Women’s and Children’s Health, Sichuan 610041 Chengdu, China
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Rahav Koren R, Miller N, Moran R, Decter D, Berkowitz A, Haikin Herzberger E, Wiser A. GnRH agonist-triggering ovulation in women with advanced age. Sci Rep 2022; 12:16401. [PMID: 36180515 PMCID: PMC9525572 DOI: 10.1038/s41598-022-20619-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 09/15/2022] [Indexed: 11/09/2022] Open
Abstract
This study evaluates the effect of GnRH agonist (GnRHa) trigger for ovulation induction among women with advanced maternal age (AMA). This is a retrospective study performed at a single assisted reproductive technology centre, 2012 to 2020. A total of 306 patients with 515 IVF cycles who were triggered with GnRHa for Ovum Pick Up (OPU), were divided into two groups according to maternal age: age ≥ 40 and age < 40. The groups were compared for demographics, stimulation parameters of IVF treatment and IVF treatment outcomes. The patients in the age < 40 group were approximately 10 years younger than the patients in the age ≥ 40 group (31 ± 5.4 vs. 41.5 ± 1.3 years, p < 0.001). The age ≥ 40 group had significantly higher mean E2/retrieved oocytes ratio, compared to the age < 40 group (310.3 ± 200.6 pg/ml vs. 239 ± 168.2 pg/ml, p = 0.003), and a lower mean MII/retrieved oocyte (35 ± 37.8 vs. 43.4 ± 35.9, p = 0.05, respectively). Multivariable logistic regression analysis for E2/retrieved oocytes demonstrated that age < 40 and total dose of gonadotropins were significant variables. In conclusion, GnRHa for ovulation triggering in high responder patients prior to OPU appears to be a good option for AMA. However, this population is characterized by different parameters of ovarian response that require further evaluation.
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Affiliation(s)
- Roni Rahav Koren
- IVF Unit, Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tchernichovsky St., 4428164, Kfar Saba, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel.
| | - Netanella Miller
- IVF Unit, Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tchernichovsky St., 4428164, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel
| | - Rimon Moran
- IVF Unit, Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tchernichovsky St., 4428164, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel
| | - Dean Decter
- IVF Unit, Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tchernichovsky St., 4428164, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel
| | - Arie Berkowitz
- IVF Unit, Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tchernichovsky St., 4428164, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel
| | - Einat Haikin Herzberger
- IVF Unit, Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tchernichovsky St., 4428164, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel
| | - Amir Wiser
- IVF Unit, Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tchernichovsky St., 4428164, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel
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Nargund G, Datta A, Campbell S, Patrizio P, Chian R, Ombelet W, Von Woolf M, Lindenberg S, Frydman R, Fauser BC. The case for mild stimulation for IVF: ISMAAR recommendations. Reprod Biomed Online 2022; 45:1133-1144. [DOI: 10.1016/j.rbmo.2022.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/25/2022] [Accepted: 07/29/2022] [Indexed: 10/16/2022]
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Jirge PR, Patil MM, Gutgutia R, Shah J, Govindarajan M, Roy VS, Kaul-Mahajan N, Sharara FI. Ovarian Stimulation in Assisted Reproductive Technology Cycles for Varied Patient Profiles: An Indian Perspective. J Hum Reprod Sci 2022; 15:112-125. [PMID: 35928474 PMCID: PMC9345274 DOI: 10.4103/jhrs.jhrs_59_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/21/2022] [Accepted: 06/23/2022] [Indexed: 11/10/2022] Open
Abstract
Controlled ovarian stimulation has been an integral part of in vitro fertilisation (IVF) treatment cycles. Availability of different gonadotropins for ovarian stimulation and gonadotropin releasing hormone (GnRH) analogues for prevention of premature rise of leutinising hormone during follicular phase offer an opportunity to utilise them for a successful outcome in women with different subsets of ovarian response. Further, use of GnRH agonist as an alternative for human chorionic gonadotropin improves safety of ovarian stimulation in hyper-responders. Mild ovarian stimulation protocols have emerged as an alternative to conventional protocols in the recent years. Individualisation plays an important role in improving safety of IVF in hyper-responders while efforts continue to improve efficacy in poor responders. Some of the follicular and peri-ovulatory phase interventions may be associated with negative impact on the luteal phase and segmentalisation of the treatment with frozen embryo transfer may be an effective strategy in such a clinical scenario. This narrative review looks at the available evidence on various aspects of ovarian stimulation strategies and their consequences. In addition, it provides a concise summary of the evidence that has emerged from India on various aspects of ovarian stimulation.
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Affiliation(s)
- Padma Rekha Jirge
- Shreyas Hospital and Sushrut Assisted Conception Clinic, Kohlhapur, India
| | | | | | - Jatin Shah
- Mumbai Fertility Clinic & IVF Centre, Mumbai, India
| | | | | | | | - Faddy I Sharara
- Virginia Center for Reproductive Medicine, Reston; Department of O&G, George Washington University, Washington, DC, USA
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22
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Kadoura S, Alhalabi M, Nattouf AH. Conventional GnRH antagonist protocols versus long GnRH agonist protocol in IVF/ICSI cycles of polycystic ovary syndrome women: a systematic review and meta-analysis. Sci Rep 2022; 12:4456. [PMID: 35292717 PMCID: PMC8924277 DOI: 10.1038/s41598-022-08400-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 03/07/2022] [Indexed: 11/09/2022] Open
Abstract
Gonadotropin-releasing hormone (GnRH) analogues are commonly used in clinical practice to prevent premature luteinizing hormone (LH) surge during In-Vitro Fertilization/ Intra-Cytoplasmic Sperm Injection (IVF/ICSI) cycles. This review aimed to summarize the available evidence comparing the effects of conventional GnRH antagonist protocols, the most commonly used GnRH antagonist protocols, and GnRH agonist protocols on IVF/ICSI outcomes in women with polycystic ovary syndrome (PCOS). A comprehensive electronic search was carried out in Pubmed, Cochrane CENTRAL, Scopus, Web of Science, CINAHL, TRIP, ClinicalTrials.gov and ISRCTN registry from inception until 24 November 2020 without any language or date restrictions. In addition, reference lists of eligible studies and previous meta-analyses were hand-searched to identify relevant studies. Eligible randomized controlled trials were those designed to compare the effects of conventional GnRH antagonist protocols and GnRH agonist protocols on IVF/ICSI outcomes in PCOS subjects. The Cochrane ROB 2.0 tool was used to assess the risk of bias of each study, and the GRADE assessment was used to evaluate the overall quality of evidence. Data synthesis and analyses were done using Review Manager 5.3 with the assistance of Revman Web. A random-effects model was used for all meta-analysis. Dichotomous outcomes were reported as Relative Risk (RR) and continuous outcomes as Weighted Mean Difference (WMD), both with 95% CIs. The primary outcomes were Live birth rate, Ongoing pregnancy rate, and Ovarian hyperstimulation syndrome (OHSS) rate. Other IVF outcomes were considered secondary outcomes. We included ten studies with 1214 randomized PCOS women. Using GnRH antagonist protocols led to a significantly lower OHSS rate (RR = 0.58; 95% CI: [0.44 to 0.77], P = 0.0002), shorter stimulation duration (WMD = - 0.91; 95% CI: [-1.45 to - 0.37] day, P = 0.0009), lower gonadotropin consumption (WMD = - 221.36; 95% CI: [- 332.28 to - 110.45] IU, P < 0.0001), lower E2 levels on hCG day (WMD = - 259.21; 95% CI: [- 485.81 to - 32.60] pg/ml, P = 0.02), thinner endometrial thickness on hCG day (WMD = - 0.73; 95% CI: [- 1.17 to - 0.29] mm, P = 0.001), and lower number of retrieved oocytes (WMD = - 1.82; 95% CI: [- 3.48 to - 0.15] oocytes, P = 0.03). However, no significant differences in live birth rate, ongoing pregnancy rate, clinical pregnancy rate, multiple pregnancy rate, miscarriage rate and cycle cancellation rate were seen between the GnRH antagonist protocols and the long GnRH agonist one. Although more cycles were cancelled due to poor ovarian response in the GnRH antagonist protocol (RR = 4.63; 95% CI: [1.49 to 14.41], P = 0.008), similar rates of cancellation due to risk of OHSS were noticed in both groups. The differences in IVF/ICSI outcomes may arise from the different patterns of gonadotropins suppression that the GnRH analogues exhibit during the early follicular phase of IVF/ICSI cycles and the divergent direct impacts of these analogues on ovaries and endometrial receptivity. The main evidence limitation was Imprecision. Conventional GnRH antagonist protocols represent a safer and more cost-effective treatment choice for PCOS women undergoing IVF/ICSI cycles than the standard long GnRH agonist protocol without compromising the IVF/ICSI clinical outcomes. The study had no sources of financial support and was prospectively registered at PROSPERO (International Prospective Register of Systematic Reviews) under registration number (CRD42021242476).
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Affiliation(s)
- Sally Kadoura
- Department of Pharmaceutics and Pharmaceutical Technology, Faculty of Pharmacy, Damascus University, Damascus, Syrian Arab Republic.
| | - Marwan Alhalabi
- Department of Embryology and Reproductive Medicine, Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic.,Assisted Reproduction Unit, Orient Hospital, Damascus, Syrian Arab Republic
| | - Abdul Hakim Nattouf
- Department of Pharmaceutics and Pharmaceutical Technology, Faculty of Pharmacy, Damascus University, Damascus, Syrian Arab Republic
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23
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Dual trigger with gonadotropin-releasing hormone agonist and recombinant human chorionic gonadotropin improves the outcome of intrauterine insemination. Obstet Gynecol Sci 2022; 65:207-214. [PMID: 35184525 PMCID: PMC8942749 DOI: 10.5468/ogs.21275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 01/10/2022] [Indexed: 11/17/2022] Open
Abstract
Objective The objective of this study was to evaluate the effectiveness of dual trigger, which is a combination of gonadotropin-releasing agonist (GnRH-a) and recombinant human chorionic gonadotropin (hCG) in the final oocyte maturation, in the outcome of intrauterine insemination (IUI). Methods This retrospective observational study was conducted from January 2016 to October 2018 and involved 639 IUI cycles at the Halim Fertility Center, Indonesia. Controlled ovarian stimulation was performed during IUI cycles. The ovulation triggers were divided into two groups: group I received a combination of GnRH-a and recombinant hCG as a dual trigger, and group II received only recombinant hCG as a single trigger. The baseline characteristics, cycle parameters, and IUI outcomes of both groups were compared. Results Our study included a total of 639 IUI cycles, 334 were in the dual trigger group and 305 in the single trigger group. The clinical pregnancy rates were significantly higher in the dual trigger group than in the single trigger group (P<0.001). Based on the multivariate analysis, the dual trigger increased the clinical pregnancy rate by 2.524 times than that by the single trigger. Conclusion Our data showed that the dual trigger combination of GnRH-a and recombinant hCG significantly improves the outcome of intrauterine insemination.
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Sallam HN, Gelbaya TA, Rosas IM, Anagnostopoulou C, Sallam N, Agarwal A. Clinical aspects of oocyte retrieval and embryo transfer. Tips and tricks for the novice and experts. Panminerva Med 2022; 64:185-199. [PMID: 35179015 DOI: 10.23736/s0031-0808.22.04679-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Oocyte retrieval (ovum pick-up) and embryo transfer (ET) are essential steps in IVF and ICSI and over the years, the two procedures were developed in order to improve the clinical outcome. Many suggestions were proposed and applied before, during and after oocyte retrieval such as timing of HCG trigger, pre-operative pelvic scan, vaginal cleansing, type of anesthesia, type and gauge of aspiration needles, aspiration pressure, follicle flushing, and the need for prophylactic antibiotics. Similarly, many steps were suggested and implemented before, during and after ET including patient's position, type of anesthesia/analgesia, dummy (mock) ET, ultrasound-guidance, HCG injection in the uterine cavity, use of relaxing agents, full bladder, removal of the cervical mucus, flushing the cervix with culture medium, type of ET catheter, embryo loading techniques, site of embryo deposition, the use of adherence compounds, as well as bed rest after ET. Complications were also reported with oocyte retrieval and ET. The aim of this review is to evaluate the current practice of these two procedures in the light of available evidence.
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Affiliation(s)
- Hassan N Sallam
- Department of Obsterics and Gynaecology, Alexandria University Faculty of Medicine, Alexandria, Egypt -
| | - Tarek A Gelbaya
- Department of Obstetrics and Gynaecology, University Hospitals of Leicester, Leicester, UK
| | - Israel M Rosas
- Citmer Reproductive Medicine, IVF LAB, Mexico City, Mexico
| | | | - Nooman Sallam
- Department of Obstetrics and Gynaecology, Guy's and St Thomas' NHS Trust, London, UK
| | - Ashok Agarwal
- Andrology Center and American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
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25
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Komiya S, Tsuzuki‐Nakao T, Asai Y, Inoue T, Morimoto Y, Okada H. The novel oral gonadotropin‐releasing hormone receptor antagonist relugolix is a new option for controlled ovarian stimulation cycles. Reprod Med Biol 2022; 21:e12448. [PMID: 35386367 PMCID: PMC8967300 DOI: 10.1002/rmb2.12448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 01/28/2022] [Accepted: 02/01/2022] [Indexed: 11/17/2022] Open
Abstract
Purpose Relugolix is an oral gonadotropin‐releasing hormone antagonist (GnRHant), which was first introduced in 2019. This study investigated the effects of the conventional injectable GnRHant formulation and this new oral GnRHant formulation on controlled ovarian stimulation (COS) cycles. Methods Relugolix was administered in 126 cycles and conventional GnRHant injection was administered in 658 cycles (controls). The follicle stimulation was performed by an antagonist method, and for final oocyte maturation, recombinant human chorionic gonadotropin (rHCG), or gonadotropin‐releasing hormone agonist (GnRHa), or both (dual trigger) were selected. The number of retrieved oocytes was counted and then they were evaluated for subsequent development up to cleavage stage. Results The number of retrieved oocytes which was the primary outcome of this research was affected by the combination of GnRHant type and the final oocyte maturation agent. The combination of relugolix and a GnRHa trigger showed a significantly lower number of retrieved oocytes (p < 0.001) than the other combinations. Conclusions Relugolix is a new option for COS cycles, but should be carefully combined with the final maturation agent. Clinical trial approval This study was conducted after approval by the Medical Corporation Sankeikai Institutional Ethics Committee (approval number: 2019‐34).
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Affiliation(s)
- Shinnosuke Komiya
- Department of Obstetrics and Gynecology Kansai Medical University Graduate School of Medicine Osaka Japan
- HORAC Grand Front Osaka Clinic Osaka Japan
| | - Tomoko Tsuzuki‐Nakao
- Department of Obstetrics and Gynecology Kansai Medical University Graduate School of Medicine Osaka Japan
| | | | | | | | - Hidetaka Okada
- Department of Obstetrics and Gynecology Kansai Medical University Graduate School of Medicine Osaka Japan
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26
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Matsumoto L, Yamakami LYS, Turco EGL, Benetti-Pinto CL, Yela DA. Use of Triggers on in vitro Fertilization and Evaluation of Risk Factors for Sub-Optimal Maturation Rate. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRICIA : REVISTA DA FEDERACAO BRASILEIRA DAS SOCIEDADES DE GINECOLOGIA E OBSTETRICIA 2022; 44:369-375. [PMID: 35108732 PMCID: PMC9948151 DOI: 10.1055/s-0041-1741455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To compare the oocyte maturation rate in the treatment of in vitro fertilization (IVF) in terms of the use of human chorionic gonadotropin (hCG), agonist gonadotropin-releasing hormone (GnRH) and dual trigger and to evaluate the associated risk factors for sub-optimal maturation rates. METHODS A retrospective cohort study with 856 women who underwent IVF. They performed oocyte retrieval and were classified into 3 groups (1 - hCG, 2 - GnRH agonist, 3 - dual trigger). The primary outcome was maturation rate per trigger, and the secondary outcomes were the pregnancy rate per oocyte retrieval and the correlations between low maturation rate as well as the clinical and treatment characteristics of women. RESULTS The maturation rate was 77% in group 1; 76% in group 2, and 83% in group 3 (p = 0.003). Group 2 showed women with better ovarian reserve, greater number of oocytes collected, and more mature oocytes and embryos compared with the other groups (p < 0.001). The cumulative clinical pregnancy rate was no different between the groups (p = 0.755). Low ovarian reserve and low doses of follicle-stimulating hormone (FSH) administered during the stimulus were associated with a higher chance of null maturation rate. CONCLUSION The oocyte maturation rates and IVF results were similar in all groups. Low ovarian reserve is associated with the worst treatment results.
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Affiliation(s)
- Larissa Matsumoto
- Department of Human Reproduction, VidaBemVinda Human Reproduction Care Center, São Paulo, SP, Brazil
| | | | - Edson Guimarães Lo Turco
- Department of Human Reproduction, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Cristina Laguna Benetti-Pinto
- Department of Gynecology and Obstetrics, Faculty Medical Sciences, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Daniela Angerame Yela
- Department of Gynecology and Obstetrics, Faculty Medical Sciences, Universidade Estadual de Campinas, Campinas, SP, Brazil
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Ganer Herman H, Horowitz E, Mizrachi Y, Farhi J, Raziel A, Weissman A. Prediction, assessment, and management of suboptimal GnRH agonist trigger: a systematic review. J Assist Reprod Genet 2022; 39:291-303. [PMID: 35306603 PMCID: PMC8956771 DOI: 10.1007/s10815-021-02359-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 11/15/2021] [Indexed: 02/03/2023] Open
Abstract
PURPOSE This systematic review aimed to identify baseline patient demographic and controlled ovarian stimulation characteristics associated with a suboptimal response to GnRHa triggering, and available options for prevention and management of suboptimal response. METHODS PubMed, Google Scholar, Medline, and the Cochrane Library were searched for keywords related to GnRHa triggering, and peer-reviewed articles from January 2000 to September 2021 included. RESULTS Thirty-seven studies were included in the review. A suboptimal response to GnRHa triggering was more likely following long-term or recent oral contraceptive use and with a low or high body mass index. Low basal serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol serum levels were correlated with suboptimal oocyte yield, as was a low serum LH level on the day of triggering. A prolonged stimulation period and increased gonadotropin requirements were correlated with suboptimal response to triggering. Post-trigger LH < 15 IU/L best correlated with an increased risk for empty follicle syndrome and a lower oocyte retrieval rate. Retriggering with hCG may be considered in patients with suboptimal response according to post-trigger LH, as in cases of failed aspiration. CONCLUSION Pre-treatment assessment of patient characteristics, with pre- and post-triggering assessment of clinical and endocrine cycle characteristics, may identify cases at risk for suboptimal response to GnRHa triggering and optimize its utilization.
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Affiliation(s)
- Hadas Ganer Herman
- grid.12136.370000 0004 1937 0546In Vitro Fertilization Unit, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Horowitz
- grid.12136.370000 0004 1937 0546In Vitro Fertilization Unit, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yossi Mizrachi
- grid.12136.370000 0004 1937 0546In Vitro Fertilization Unit, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jacob Farhi
- grid.12136.370000 0004 1937 0546In Vitro Fertilization Unit, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arieh Raziel
- grid.12136.370000 0004 1937 0546In Vitro Fertilization Unit, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ariel Weissman
- grid.12136.370000 0004 1937 0546In Vitro Fertilization Unit, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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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.
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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.
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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.
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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,
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Merkison J, Malcom C, Decherney A. Use of gonadotropin-releasing hormone (GnRH) agonist trigger in fertility preservation for patients with inherited genetic disorders. Front Endocrinol (Lausanne) 2022; 13:826419. [PMID: 36147559 PMCID: PMC9486700 DOI: 10.3389/fendo.2022.826419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 07/28/2022] [Indexed: 11/20/2022] Open
Abstract
In patients with varying hematologic disorders (thalassemia, sickle cell anemia, aplastic anemia, etc.), inherited bone marrow failure syndromes, and immune deficiencies due to a single gene disorder, the advent of stem cell transplantation (SCT) as a treatment option has allowed for significant disease improvement, and possibly cure. This specific treatment option often requires exposure to chemotherapeutic agents and sometimes whole body radiation; therefore, primary ovarian insufficiency is often sequelae of the therapy. The optimization of fertility preservation protocols within this patient population is of extreme importance. This review aims to detail the use of GnRH agonist use within this patient population, within the context of fertility preservation cycles.
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Affiliation(s)
- Jamie Merkison
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, The National Institutes of Health, Bethesda, MD, United States
| | - Carrie Malcom
- Department of Obstetrics and Gynecology, Jackson Health System, Miami, FL, United States
| | - Alan Decherney
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, The National Institutes of Health, Bethesda, MD, United States
- *Correspondence: Alan Decherney,
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Yan MH, Cao JX, Hou JW, Jiang WJ, Wang DD, Sun ZG, Song JY. GnRH Agonist and hCG (Dual Trigger) Versus hCG Trigger for Final Oocyte Maturation in Expected Normal Responders With a High Immature Oocyte Rate: Study Protocol for a Randomized, Superiority, Parallel Group, Controlled Trial. Front Endocrinol (Lausanne) 2022; 13:831859. [PMID: 35418945 PMCID: PMC8996168 DOI: 10.3389/fendo.2022.831859] [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: 12/09/2021] [Accepted: 03/03/2022] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION The choice of trigger drug for the controlled ovarian hyperstimulation (COH) protocol correlates with the outcome of in vitro fertilization/intracytoplasmic sperm injection embryo transfer (IVF/ICSI-ET). The co-administration of gonadotropin releasing hormone agonist (GnRH-a) and human chorionic gonadotropin (hCG), i.e., dual trigger, for final oocyte maturation, has received much attention in recent years. This trial was designed to determine whether a dual trigger approach by lengthening the time between trigger and ovum pick-up (OPU) improves the quantity and quality of mature oocytes/top-quality embryos and pregnancy outcomes in expected normal responders with a high immature oocyte rate. METHODS AND ANALYSIS We propose a study at the Affiliated Hospital of Shandong University of Chinese Medicine. A total of 90 individuals undergoing COH use a fixed GnRH antagonist protocol. They will be assigned randomly into two groups according to the trigger method and timing: recombinant hCG (6500 IU) will be injected only 36 hours before OPU for final oocyte maturation (hCG-only trigger); co-administration of GnRH-a and hCG for final oocyte maturation, 40 and 34 hours prior to OPU, respectively (Dual trigger). The primary outcome is metaphase-II (MII) oocytes rate. Secondary outcomes are number of oocytes retrieved, fertilization rate, top-quality embryos rate, blastula formation rate, embryo implantation rate, clinical pregnancy rate, miscarriage rate, live birth rate, cumulative pregnancy/live birth rates, and ovarian hyperstimulation syndrome (OHSS) rate. ETHICS AND DISSEMINATION The reproductive ethics committee of the Affiliated Hospital of Shandong University of Traditional Chinese Medicine certified this study (Identifier: SDUTCM/2021.7.26) as ethical. All individuals will sign written informed consent. All data and biological samples will be protected according to law. The results of this study will be disseminated in a peer-reviewed scientific journal. CLINICAL TRIAL REGISTRATION [chictr.gov.cn], identifier [ChiCTR2100049292].
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Affiliation(s)
- Meng-Han Yan
- The College of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Jing-Xian Cao
- The First Clinical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Jin-Wei Hou
- The First Clinical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Wen-Jing Jiang
- The First Clinical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Dan-Dan Wang
- The First Clinical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Zhen-Gao Sun
- The First Clinical College, Shandong University of Traditional Chinese Medicine, Jinan, China
- Reproductive Center of Integrated Medicine, The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
- *Correspondence: Jing-Yan Song, ; Zhen-Gao Sun,
| | - Jing-Yan Song
- The First Clinical College, Shandong University of Traditional Chinese Medicine, Jinan, China
- Reproductive Center of Integrated Medicine, The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
- *Correspondence: Jing-Yan Song, ; Zhen-Gao Sun,
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Martazanova B, Mishieva N, Vedikhina I, Kirillova A, Korneeva I, Ivanets T, Abubakirov A, Sukhikh GT. Hormonal profile in early luteal phase after triggering ovulation with gonadotropin-releasing hormone agonist in high-responder patients. Front Endocrinol (Lausanne) 2022; 13:834627. [PMID: 36046787 PMCID: PMC9420862 DOI: 10.3389/fendo.2022.834627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 07/19/2022] [Indexed: 11/26/2022] Open
Abstract
The major limitations associated with gonadotropin-releasing hormone agonist (GnRHa) triggering are inferior clinical outcomes in fresh embryo transfer cycles caused by luteal phase insufficiency following the GnRHa triggering. We included 153 high-risk patients in this study. In group I, the patients received gonadotropin-releasing hormone agonist (GnRHa) trigger + 1,500 IU human chorionic gonadotropin (hCG) support on the oocyte pick-up (OPU) day; in group II, the patients had a dual trigger (GnRHa + 1,500 IU hCG); and in group III (control), 10,000 IU hCG trigger was prescribed for the final oocyte maturation. The levels of LH, estradiol, and progesterone were evaluated in serum on the stimulation starting day, day 6 of stimulation, on the day of the trigger administration, OPU day, days 3 and 5 post-OPU, and day 14 post-ET, as well as in follicular fluid. Progesterone concentration was significantly lower in group I on OPU+5 compared to the hCG group (I vs. III, р = 0.0065). Progesterone levels were significantly lower in group II in serum on OPU+5 compared to groups I and III (I vs. II, р = 0.0068; II vs. III, р = 1.76 × 108). The progesterone levels were significantly higher in follicular fluid in group III compared to the study groups (I vs. III, р = 0.002; II vs. III, p = 0.009). However, no significant differences in clinical outcomes were found between the groups. Then, we divided all women into pregnant and non-pregnant groups and found that estradiol (p = 0.00009) and progesterone (p = 0.000036) on the day of the pregnancy test were significantly higher in the pregnant women group. Also, progesterone on OPU day was significantly higher in the non-pregnant group (p = 0.033). Two cases of moderate ovarian hyperstimulation syndrome (OHSS) late-onset occurred in group I (3.5%, 2/56), no case of moderate/severe OHSS late-onset in group II, and three cases of moderate late-onset in group III (5.7%, 3/53). The low-dose hCG supplementation improves the luteal phase insufficiency after GnRHa triggering, which is confirmed by the comparable pregnancy rates in fresh transfer cycles between the groups. However, low-dose hCG carries a similar risk of OHSS as the full dose of hCG in high-responder patients.
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Nargund G, Datta AK. Maximizing live birth rates cannot be the only key performance indicator of IVF. Reprod Biomed Online 2021; 44:587-589. [PMID: 35031242 DOI: 10.1016/j.rbmo.2021.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/09/2021] [Accepted: 11/12/2021] [Indexed: 01/11/2023]
Abstract
The success of IVF is currently measured by pregnancy or live birth rate only, without any consideration given to health outcomes for the woman and baby and the total cost of treatment. A successful IVF cycle should be redefined as the birth of a healthy singleton baby at term, without compromising the health and safety of the woman and baby achieved at the lowest possible cost. We recommend that the performance indices for an IVF programme should be based on a weighted scoring system according to live birth per embryo transferred, cumulative live birth rate over 1 year, total cost of treatment cycle and maternal and perinatal outcomes. This holistic approach would prevent the use of unnecessary high stimulation, unproven add-ons without regard for the welfare of the patients and would increase accessibility to IVF treatment.
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Affiliation(s)
- Geeta Nargund
- Create Fertility, London, 150 Cheapside, St Paul's London EC2 V6ET, St George's Hospital NHS Trust, Blackshaw Road SW17 0QT.
| | - Adrija Kumar Datta
- Create Fertility, Birmingham, 6270 Bishops Court, Solihull Parkway, Birmingham Business Park, Birmingham B37 7YB
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Huang TC, Huang MZ, Seow KM, Yang IJ, Pan SP, Chen MJ, Hwang JL, Chen SU. Progestin primed ovarian stimulation using corifollitropin alfa in PCOS women effectively prevents LH surge and reduces injection burden compared to GnRH antagonist protocol. Sci Rep 2021; 11:22732. [PMID: 34815477 PMCID: PMC8611037 DOI: 10.1038/s41598-021-02227-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 11/09/2021] [Indexed: 12/28/2022] Open
Abstract
Utilizing corifollitropin alfa in GnRH antagonist (GnRHant) protocol in conjunction with GnRH agonist trigger/freeze-all strategy (corifollitropin alfa/GnRHant protocol) was reported to have satisfactory outcomes in women with polycystic ovary syndrome (PCOS). Although lessening in gonadotropin injections, GnRHant were still needed. In addition to using corifollitropin alfa, GnRHant was replaced with an oral progestin as in progestin primed ovarian stimulation (PPOS) to further reduce the injection burden in this study. We try to investigate whether this regimen (corifollitropin alfa/PPOS protocol) could effectively reduce GnRHant injections and prevent premature LH surge in PCOS patients undergoing IVF/ICSI cycles. This is a retrospective cohort study recruiting 333 women with PCOS, with body weight between 50 and 70 kg, undergoing first IVF/ICSI cycle between August 2015 and July 2018. We used corifollitropin alfa/GnRHant protocol prior to Jan 2017 (n = 160), then changed to corifollitropin alfa/PPOS protocol (n = 173). All patients received corifollitropin alfa 100 μg on menstruation day 2/3 (S1). Additional rFSH was administered daily from S8. In corifollitropin alfa/GnRHant group, cetrorelix 0.25 mg/day was administered from S5 till the trigger day. In corifollitropin alfa/PPOS group, dydrogesterone 20 mg/day was given from S1 till the trigger day. GnRH agonist was used to trigger maturation of oocyte. All good quality day 5/6 embryos were frozen, and frozen-thawed embryo transfer (FET) was performed on subsequent cycle. A comparison of clinical outcomes was made between the two protocols. The primary endpoint was the incidence of premature LH surge and none of the patients occurred. Dydrogesterone successfully replace GnRHant to block LH surge while an average of 6.8 days of GnRHant injections were needed in the corifollitropin alfa/GnRHant group. No patients suffered from ovarian hyperstimulation syndrome (OHSS). The other clinical outcomes including additional duration/dose of daily gonadotropin administration, number of oocytes retrieved, and fertilization rate were similar between the two groups. The implantation rate, clinical pregnancy rate, and live birth rate in the first FET cycle were also similar between the two groups. In women with PCOS undergoing IVF/ICSI treatment, corifollitropin alfa/PPOS protocol could minimize the injections burden with comparable outcomes to corifollitropin alfa/GnRHant protocol.
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Affiliation(s)
- Ting-Chi Huang
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, No. 7 Chung-Shan South Road, Taipei, Taiwan
| | - Mei-Zen Huang
- Department of Nursing, National Tainan Junior College of Nursing, Tainan, Taiwan
| | - Kok-Min Seow
- Department of Obstetrics and Gynecology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Obstetrics and Gynecology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Ih-Jane Yang
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, No. 7 Chung-Shan South Road, Taipei, Taiwan
| | - Song-Po Pan
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, No. 7 Chung-Shan South Road, Taipei, Taiwan
| | - Mei-Jou Chen
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, No. 7 Chung-Shan South Road, Taipei, Taiwan
| | - Jiann-Loung Hwang
- Department of Obstetrics and Gynecology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.,Taipei IVF, Center for Reproduction and Genetics, Taipei, Taiwan.,Department of Obstetrics and Gynecology, Taipei Medical University, Taipei, Taiwan
| | - Shee-Uan Chen
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, No. 7 Chung-Shan South Road, Taipei, Taiwan.
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Sharma R, Meena I. To Compare the Effect of GnRH Agonist versus Human Chorionic Gonadotropin (HCG) Trigger on Clinical Pregnancy Rate in Intrauterine Insemination Cycle. J Hum Reprod Sci 2021; 14:267-272. [PMID: 34759616 PMCID: PMC8527070 DOI: 10.4103/jhrs.jhrs_100_20] [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: 07/13/2020] [Revised: 03/26/2021] [Accepted: 06/09/2021] [Indexed: 11/05/2022] Open
Abstract
Context: Gonadotropin-releasing hormone (GnRH) agonist trigger mimics the natural surge more closely with both luteinizing hormone (LH) and follicle-stimulating hormone surge. The present study attempts to find whether this apparent physiological advantage translates into the better pregnancy rate. Aims: To compare the effect of GnRH agonist versus human chorionic gonadotropin (hCG) trigger on the clinical pregnancy rate (CPR) in infertile women undergoing intrauterine insemination (IUI) with oral ovulogens. Settings and Design: Retrospective analysis at a tertiary care in vitro fertilization center. Materials and Methods: The records of 280 infertile women, who underwent IUI with oral ovulogens were analyzed. Women who received 0.2 mg triptorelin (GnRH agonist (GnRHa)) as trigger were categorised in Group A (n = 129) and those who received 10,000 IU urinary hCG in Group B (n = 151). The outcome in terms of CPR was studied. Statistical Analysis Used: The quantitative variables were compared using the independent t-test/Mann–Whitney test. The qualitative variables were compared using the Chi-square test. P < 0.05 was considered statistically significant. Results: There was a trend toward better CPR in Group A (21/129 – 16.28%) than in Group B (16/151 – 10.60%), although the difference was not found to be statistically significant (P – 0.162). Conclusions: There was a trend toward better CPR with the use of GnRH agonist trigger in IUI cycles with oral ovulogens in comparison to hCG trigger, although the difference was not found to be statistically significant. Further randomized controlled trials are needed to confirm these findings.
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Affiliation(s)
- Rashmi Sharma
- IVF and Reproductive medicine, Origyn fertility and IVF, 4 floor HB Twin Tower-2 NSP Near D Mall, Pitampura New Delhi -110 034, India
| | - Imlesh Meena
- IVF and Reproductive medicine, Origyn fertility and IVF, 4 floor HB Twin Tower-2 NSP Near D Mall, Pitampura New Delhi -110 034, India
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Duarte-Filho OB, Podgaec S. Freeze-all policy for in vitro fertilization in women with normal response to ovarian stimulation. EINSTEIN-SAO PAULO 2021; 19:eAO6290. [PMID: 34644745 PMCID: PMC8483637 DOI: 10.31744/einstein_journal/2021ao6290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 04/08/2021] [Indexed: 11/29/2022] Open
Abstract
Objective To answer the question if the freeze-all strategy and subsequent frozen embryo transfer is preferable to fresh embryo transfer for patients with normal response to ovarian stimulation (4 to 15 oocytes recovered) during in vitro fertilization treatments. Methods A retrospective cohort from two human reproduction centers between 2013 and 2017. A total of 471 frozen embryo transfers from freeze-all cycles, and 3,208 fresh transfers were included. Results After propensity score matching adjustment for age and number of eggs, 467 freeze-all cycles and 934 fresh cycles were analyzed, revealing no statistically significant difference between groups in relation to clinical pregnancy rate (32.5% in the Freeze-all Group and 32.3% in the Fresh Group, p=0.936). For women aged 40 years and older, we observed a statistically significant higher clinical pregnancy rate when freeze-all strategy was used (29.3% in the Freeze-all Group and 19.8% in the Fresh Group, p=0.04). Conclusion Freeze-all strategy was not superior to fresh transfer for all patients with normal response to ovarian stimulation. However, women aged 40 years and older could benefit from this strategy. This deserves further investigation in future research, preferable in a prospective randomized study.
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Affiliation(s)
| | - Sérgio Podgaec
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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Kalafat E, Benlioğlu C, Gökçe A, Şükür YE, Özmen B, Sönmezer M, Atabekoğlu CS, Aytaç R, Berker B. Factors associated with livebirth in couples undergoing their first in vitro fertilization cycle: An internally validated prediction model. Turk J Obstet Gynecol 2021; 18:212-220. [PMID: 34580695 PMCID: PMC8480211 DOI: 10.4274/tjod.galenos.2021.71770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective: The aim of the study is to create a new model to predict successful outcome in assisted reproductive techniques. Materials and Methods: A retrospective cohort study was conducted in tertiary fertility center between 2010 and 2017. Nulliparous women younger than 45 years-old undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) for the first time were included; frozen embryo transfers, canceled induction cycles, freeze-all cycles were excluded. Two prediction models were built using multivariate logistic regression with a subset of the dataset and then were internally validated using bootstrapping methods. Results: Four hundred eighty eight women were included with 136 (27.9%) live births. The basal model was built using variable age, antral follicle count (AFC), and basal luteinizing hormone (LH) levels. Age over 37 years [odds ratio (OR): 0.07, 95% confidence interval (CI): 0.00-0.36] and AFC below 5 (OR: 0.15, 95% CI: 0.02-0.53) was associated with poorer outcomes whereas an LH level above 6 mIU/mL (OR: 2.24, 95% CI: 1.27-3.94) was associated with better outcomes. Optimism adjusted area under the curve (AUC) of this model was 0.68 (95% CI: 0.62-0.74). Combined model in addition to basal model variables included the length of induction cycle, the endometrial thickness at the day of transfer, grade and count of the transferred embryo. Cycles lasting more than ten days (OR: 2.23, 95% CI: 1.17-4.42), an endometrial thickness greater than 9 mm (OR: 2.07, 95% CI: 1.00-4.53) were associated with better outcomes. Optimism adjusted AUC of this model was 0.76 (95% CI: 0.70-0.81). Calibration of both models was good according to Hosmer Lemeshow test (p=0.979 and p=0.848, respectively). Conclusion: This internally validated prediction model has good calibration and can be used predicting outcomes in first time IVF/ICSI cycles with modest sensitivity.
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Affiliation(s)
- Erkan Kalafat
- Ankara University Faculty of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey
| | - Can Benlioğlu
- Doğubeyazıt State Hospital, Ministry of Health, Ağrı, Turkey
| | - Ali Gökçe
- Yıldırım Beyazıt University, Yenimahalle Training and Research Hospital, Ankara, Turkey
| | - Yavuz Emre Şükür
- Ankara University Faculty of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey
| | - Batuhan Özmen
- Ankara University Faculty of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey
| | - Murat Sönmezer
- Ankara University Faculty of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey
| | - Cem Somer Atabekoğlu
- Ankara University Faculty of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey
| | - Ruşen Aytaç
- Ankara University Faculty of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey
| | - Bülent Berker
- Ankara University Faculty of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey
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Chung RK, Mancuso AC, Summers KM, Sparks AE, Duran HE, Mejia RB. Dual trigger protocol is an effective in vitro fertilization strategy in both normal and high responders without compromising pregnancy outcomes in fresh cycles. F S Rep 2021; 2:314-319. [PMID: 34553157 PMCID: PMC8441566 DOI: 10.1016/j.xfre.2021.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 05/18/2021] [Accepted: 05/24/2021] [Indexed: 11/26/2022] Open
Abstract
Objective To study the birth rates of normal vs. high responders after dual trigger of final oocyte maturation with gonadotropin-releasing hormone (GnRH) agonist and human chorionic gonadotropin in fresh in vitro fertilization (IVF) cycles in which ovarian stimulation was achieved by a flexible GnRH antagonist protocol. Design Retrospective cohort study. Setting University hospital. Patient(s) In women <35 years of age, 290 fresh IVF cycles using the dual trigger protocol with day 5 embryo transfers from January 2013 to July 2018 were included. Cycles excluded were those with preimplantation genetic testing, gestational carriers, donor oocytes, and fertility preservation. Intervention(s) IVF with dual trigger. Main Outcome Measure(s) Clinical pregnancy rate, live birth rate. Result(s) Comparing normal responders, defined as <30 oocytes retrieved, and high responders, defined as ≥30 oocytes retrieved, the clinical pregnancy rates (67.0% vs. 69.3%, respectively) and live birth rates (60.5% vs. 60.0%, respectively) were not significantly different. No cases of ovarian hyperstimulation syndrome were reported in either group. Conclusion(s) Ovarian stimulation by a flexible GnRH antagonist protocol followed by dual trigger yields comparable outcomes between normal and high responders in fresh IVF cycles.
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Affiliation(s)
- Rebecca K. Chung
- Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
- Reprint requests: Rebecca K. Chung, M.D., University Hospitals Fertility Center, 1000 Auburn Drive, Suite 310, Beachwood, Ohio 44122.
| | - Abigail C. Mancuso
- Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Karen M. Summers
- Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Amy E. Sparks
- Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Hakan E. Duran
- Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Rachel B. Mejia
- Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Elmahal M, Lohana P, Anvekar P, Menda MK, Arti. Hyponatremia: An Untimely Finding in Ovarian Hyper-Stimulation Syndrome. Cureus 2021; 13:e16556. [PMID: 34431837 PMCID: PMC8380000 DOI: 10.7759/cureus.16556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2021] [Indexed: 11/05/2022] Open
Abstract
In-vitro fertilization (IVF) is one of several methods to assist individuals to conceive. This is a case of a young lady who presented to the emergency department with a one-day history of mild abdominal pain, vomiting, and tiredness. She had undergone uneventful IVF with an embryo transfer procedure in a specialized center three days earlier. The initial clinical examination was unremarkable, but laboratory investigations showed low serum sodium and albumin levels with relatively high leucocyte count. Considering the recent history of IVF coupled with the deranged laboratory results, the patient was admitted to the hospital for further assessment and evaluation. On the second day, the patient developed severe abdominal pain and distension and she became more distressed. A diagnosis of ovarian hyperstimulation syndrome (OHSS) was established and the patient was admitted to the intensive care unit (ICU) as her condition deteriorated thereafter. Twelve days later, the patient was discharged from the hospital after a full recovery.
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Affiliation(s)
| | - Petras Lohana
- Internal Medicine, Liaquat University of Medical and Health Sciences Hospital, Karachi, PAK
| | - Priyanka Anvekar
- Internal Medicine and Surgery, Mahatma Gandhi Mission (MGM) Medical College and Hospital, Mumbai, IND
| | - Manoj K Menda
- Medicine, St Johns National Academy of Health Sciences, Bangalore, IND
| | - Arti
- Internal Medicine, Liaquat University of Medical and Health Sciences, Kunri, PAK
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40
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Chimote BN, Chimote NM. Fertility interventions 'add-ons' in clinical ART practice: Ethical, Moral and Commercial Considerations. J Assist Reprod Genet 2021; 38:2579-2580. [PMID: 34387793 DOI: 10.1007/s10815-021-02288-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/27/2021] [Indexed: 11/25/2022] Open
Affiliation(s)
- Bindu N Chimote
- Embryology and Reproductive Endocrinology, Vaunshdhara Fertility Centre, Nagpur, India, 440012.
| | - Natchandra M Chimote
- Embryology and Reproductive Endocrinology, Vaunshdhara Fertility Centre, Nagpur, India, 440012
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Vidal A, Wachter C, Kohl Schwartz A, Dhakal C. A rare presentation of isolated right-sided pleural effusion in the context of ovarian hyperstimulation syndrome: A case report. Case Rep Womens Health 2021; 32:e00347. [PMID: 34401398 PMCID: PMC8350452 DOI: 10.1016/j.crwh.2021.e00347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 07/24/2021] [Accepted: 07/26/2021] [Indexed: 11/27/2022] Open
Abstract
An isolated pleural effusion as the sole manifestation of early ovarian hyperstimulation syndrome (OHSS) is rare. A 38-year-old woman who had undergone in vitro fertilization presented with OHSS. Six days after transvaginal oocyte pickup, she presented with only an isolated right-sided pleural effusion and restricted respiratory capacity. A thoracentesis was successfull. Clinicians must be aware of unilateral pleural effusion, with a higher incidence on the right side, as a single-symptom presentation of OHSS. The case reported here illustrates the diversity and severity of OHSS.
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Affiliation(s)
- Angela Vidal
- Division of Gynecological Endocrinology and Reproductive Medicine, Lucerne Cantonal Hospital, Switzerland
| | - Christiane Wachter
- Division of Gynecological Endocrinology and Reproductive Medicine, Lucerne Cantonal Hospital, Switzerland
| | - Alexandra Kohl Schwartz
- Division of Gynecological Endocrinology and Reproductive Medicine, Lucerne Cantonal Hospital, Switzerland
| | - Carolin Dhakal
- Division of Gynecological Endocrinology and Reproductive Medicine, Lucerne Cantonal Hospital, Switzerland
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Iorio GG, Rovetto MY, Conforti A, Carbone L, Vallone R, Cariati F, Bagnulo F, Di Girolamo R, La Marca A, Alviggi C. Severe Ovarian Hyperstimulation Syndrome in a Woman With Breast Cancer Under Letrozole Triggered With GnRH Agonist: A Case Report and Review of the Literature. FRONTIERS IN REPRODUCTIVE HEALTH 2021; 3:704153. [PMID: 36303992 PMCID: PMC9580822 DOI: 10.3389/frph.2021.704153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 06/10/2021] [Indexed: 11/13/2022] Open
Abstract
We report a rare case of ovarian hyperstimulation syndrome (OHSS) in a 28-year-old woman with breast cancer and with a history of polycystic ovary syndrome (PCOS) despite treatment with letrozole and gonadotropin-releasing hormone agonist (GnRH-a) triggering in a GnRH antagonist (GnRH-ant) protocol without the administration of any human chorionic gonadotropin (hCG) for luteal-phase support. The patient, who underwent controlled ovarian syndrome (COS)-oocyte cryopreservation before chemotherapy, required hospitalization. Complete recovery was achieved after treatment with volume expanders, human albumin, and cabergoline. Based on our case and literature review, it is possible to establish that estradiol (E2) modulation with letrozole and GnRH-a triggering does not eliminate the risk of OHSS. Furthermore, it is advisable to postpone GnRH-a depot to minimize the risk of OHSS after the suspension of letrozole, following menstruation or at least 7–8 days after triggering. It would be desirable to identify high-risk patients, also on a genetic basis, in order to avoid delays in oncologic treatments that could strongly impact life expectancy.
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Affiliation(s)
- Giuseppe Gabriele Iorio
- Department of Neuroscience, Reproductive Science and Odontostomatology, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
- *Correspondence: Giuseppe Gabriele Iorio orcid.org/0000-0002-1723-3420
| | - Marika Ylenia Rovetto
- Department of Neuroscience, Reproductive Science and Odontostomatology, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Alessandro Conforti
- Department of Neuroscience, Reproductive Science and Odontostomatology, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Luigi Carbone
- Department of Neuroscience, Reproductive Science and Odontostomatology, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Roberta Vallone
- Department of Neuroscience, Reproductive Science and Odontostomatology, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Federica Cariati
- Department of Neuroscience, Reproductive Science and Odontostomatology, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Francesca Bagnulo
- Department of Neuroscience, Reproductive Science and Odontostomatology, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Raffaella Di Girolamo
- Department of Obstetrics and Gynecology, Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - Antonio La Marca
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Carlo Alviggi
- Department of Neuroscience, Reproductive Science and Odontostomatology, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
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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.
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Shapiro M, Romanski P, Thomas A, Lanes A, Yanushpolsky E. Low dose hCG supplementation in a Gn-RH-agonist trigger protocol is associated with worse pregnancy outcomes: a retrospective cohort study. FERTILITY RESEARCH AND PRACTICE 2021; 7:12. [PMID: 34049598 PMCID: PMC8161625 DOI: 10.1186/s40738-021-00104-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 05/09/2021] [Indexed: 12/01/2022]
Abstract
Background A number of studies have looked at dual triggers with hCG and GnRH agonist (GnRHa) in varying doses, but the question remains: what is the optimal dose of hCG to minimize ovarian hyperstimulation syndrome (OHSS) and still offer adequate pregnancy rates? The purpose of this study was to compare pregnancy and OHSS rates following dual trigger for oocyte maturation with GnRHa and a low-dose hCG versus hCG alone. A secondary objective was the assess pregnancy outcomes in subsequent frozen cycles for the same population. Methods A total of 963 women < 41 years old, with a BMI 18–40 kg/m2 and an AMH > 2 ng/mL who underwent fresh autologous in vitro fertilization (IVF) with GnRH antagonist protocol at a University-based fertility center were included in this retrospective cohort study. Those who received a low dose dual trigger with hCG (1000u) and GnRHa (2 mg) were compared to those who received hCG alone (10,000u hCG/250-500 μg Ovidrel). Differences in implantation rates, pregnancy, live birth, and OHSS were investigated. Results The dual trigger group was younger (mean 33.6 vs 34.1 years), had a higher AMH (6.3 vs 4.9 ng/mL,) more oocytes retrieved (18.1 vs 14.9) and a higher fertilized oocyte rate (80% vs 77%) compared with the hCG only group. Yet, the dual trigger group had a lower probability of clinical pregnancy (gestational sac, 43.4% vs 52.8%) and live birth (33.4% vs 45.8%), all of which were statistically significant. There were 3 cases of OHSS, all in the hCG-only trigger group. In subsequent frozen cycles, pregnancy rates were comparable between the two groups. Conclusions The dual trigger group had a better prognosis based on age and AMH levels and had better stimulation outcomes, but significantly worse pregnancy outcomes, suggesting the low dose hCG (1000u) in the dual trigger may not have provided adequate luteal support, compared to an hCG-only trigger (10,000u hCG/250-500 μg Ovidrel). Interestingly, the pregnancy rates were comparable in subsequent frozen cycles, further supporting the hypothesis that the issue lies in inadequate luteal phase support, rather than embryo quality. Based on these findings, our program has changed the protocol to 1500u of hCG in a dual trigger.
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Affiliation(s)
- Maren Shapiro
- Obstetrics & Gynecology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA. .,Center for Reproductive Health, University of California, 499 Illinois Street, 6th floor, San Francisco, CA, 94158, USA.
| | - Phillip Romanski
- Obstetrics & Gynecology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Ann Thomas
- Obstetrics & Gynecology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrea Lanes
- Obstetrics & Gynecology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Elena Yanushpolsky
- Obstetrics & Gynecology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Griesinger G. Lutealphase – neue Entwicklungen im Kontext der assistierten Reproduktion. GYNAKOLOGISCHE ENDOKRINOLOGIE 2021. [DOI: 10.1007/s10304-020-00375-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Oliveira CMD, Oliveira CAMD, Fonseca LL, Souza KRRD, Radaelli MRM. GnRH agonist in association with hCG versus hCG alone for final oocyte maturation triggering in GnRH antagonist cycles. JBRA Assist Reprod 2021; 25:246-251. [PMID: 33507721 PMCID: PMC8083849 DOI: 10.5935/1518-0557.20200089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Objective: To analyze gonadotropin-releasing hormone (GnRH) agonist in association with human chorionic gonadotropin (hCG) (dual triggering) versus hCG alone (conventional triggering) for final oocyte maturation triggering in GnRH antagonist cycles in an unselected population of Brazilian women. Methods: This prospective case-control study involved 114 patients referred to autologous in vitro fertilization treatment between February 2018 and August 2019, recruited regardless of age, infertility factor or number of cycles. The patients were randomly allocated into two groups according to oocyte maturation triggering approach: group A (n = 48) - hCG only; and group B (n = 66) - hCG plus GnRH agonist. The main outcomes measured were the number of total and metaphase II (MII) oocytes retrieved. Results: The groups were homogenous in terms of age. There were no moderate or severe ovarian hyperstimulation syndrome events. There were no statistical differences concerning total or MII oocytes retrieved between the groups (p > 0.05). The MII/total oocyte rate was 70.9% in group A, and 74.5% in group B (p = 0.679). There was no oocyte retrieved in 2/48 patients (4.16%) in group A, 1/66 (1.5%) in group B. There were no MII oocytes in 4/48 patients (8.3%) in group A, and 2/66 (3%) in group B. Age was directly correlated to the number of total and MII oocytes retrieved (p < 0.05). Conclusions: Dual triggering was equivalent to conventional hCH triggering in terms of the number of total and MII oocytes retrieved in the general population. Further studies are necessary to ascertain dual triggering indication in selected groups of women.
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Chua SJ, Mol BW, Longobardi S, Orvieto R, Venetis CA, Lispi M, Storr A, D'Hooghe T. Biosimilar recombinant follitropin alfa preparations versus the reference product (Gonal-F®) in couples undergoing assisted reproductive technology treatment: a systematic review and meta-analysis. Reprod Biol Endocrinol 2021; 19:51. [PMID: 33794909 PMCID: PMC8017804 DOI: 10.1186/s12958-021-00727-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/04/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Live birth has increasingly been identified as the standard clinical approach to measure the success of medically assisted reproduction (MAR). However, previous analyses comparing biosimilar preparations of follitropin alfa versus the reference product (GONAL-f®, Merck KGaA, Darmstadt, Germany or GONAL-f® RFF; EMD Serono, Inc., Rockland, MA), have had insufficient power to detect differences in clinically meaningful outcomes such as live birth. METHODS Medline, Embase, the Cochrane Library, Web of Science and clinical trial registries were searched for randomised controlled trials (RCTs) and conference abstracts comparing biosimilar follitropin alfa versus the reference product in controlled ovarian stimulation (COS) cycles published before 31 October 2020. Only studies in humans and publications in English were included. Retrieved studies were screened independently by two authors based on titles and abstracts, and then by full text. INCLUSION CRITERIA RCTs comparing follitropin alfa biosimilar preparations with the reference product in infertile patients of any age, with any type of infertility for any duration, undergoing COS for the purposes of MAR treatment (including frozen cycles). The primary outcome was live birth. Combined data for biosimilar preparations were analysed using a fixed-effects model. RESULTS From 292 unique records identified, 17 studies were included in the systematic review, representing five unique RCTs that were included in the meta-analysis. Rates of live birth (RR = 0.83, 95% CI 0.71, 0.97; 4 RCTs, n = 1881, I2 = 0%), clinical pregnancy (RR = 0.82, 95% CI 0.72, 0.94; 4 RCTs, n = 2222, I2 = 0%) and ongoing pregnancy (RR = 0.81, 95% CI 0.68, 0.96; 4 RCTs, n = 1232, I2 = 0%) were significantly lower with biosimilar preparations versus the reference product. Rates of cumulative live birth and cumulative clinical pregnancy were also significantly lower with biosimilars versus the reference product. There was high risk of publication bias. CONCLUSIONS This meta-analysis included data from RCTs evaluating the efficacy and safety of the biosimilar follitropin alfa preparations and demonstrated lower probability of live birth and pregnancy (ongoing and clinical) in couples treated with biosimilar preparations compared with the reference product. This study provides more insight into the differences between biosimilar r-hFSH preparations and the reference product than previously reported. TRIAL REGISTRATION Registration number: CRD42019121992 .
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Affiliation(s)
- Su Jen Chua
- Austin Health, Heidelberg, VIC, 3084, Australia.
| | - Ben W Mol
- Department of Obstetrics and Gynecology, University of Monash, Monash, Clayton, Victoria, 3168, Australia
| | - Salvatore Longobardi
- Global Clinical Development, Merck Serono S.p.A (an affiliate of Merck KGaA, Darmstadt 64293, Germany), 00176, Rome, Italy
| | - Raoul Orvieto
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, 52621, Israel
- The Tarnesby-Tarnowski Chair for Family Planning and Fertility Regulation, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, 6997801, Israel
| | - Christos A Venetis
- School of Women's and Children's Health & Centre for Big Data Research in Health, University of New South Wales, Clayton, Victoria, 2052, Australia
- IVF Australia, Sydney, NSW, 2000, Australia
| | - Monica Lispi
- University of Modena and Reggio Emilia, Modena, MO, 41121, Italy
- Global Medical Affairs Fertility, Research and Development, Merck KGaA, F135/002, Darmstadt, 64293, Germany
| | - Ashleigh Storr
- Flinders Fertility, Adelaide, South Australia, 5045, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, 5042, Australia
| | - Thomas D'Hooghe
- Global Medical Affairs Fertility, Research and Development, Merck KGaA, F135/002, Darmstadt, 64293, Germany
- Research Group Reproductive Medicine, Department of Development and Regeneration, Organ Systems, Group Biomedical Sciences, KU Leuven (University of Leuven), Leuven, 3000, Belgium
- Department of Obstetrics and Gynecology, Yale University, New Haven, CT, 06510, USA
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Oocyte competence is independent of the ovulation trigger adopted: a large observational study in a setting that entails vitrified-warmed single euploid blastocyst transfer. J Assist Reprod Genet 2021; 38:1419-1427. [PMID: 33661465 DOI: 10.1007/s10815-021-02124-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/21/2021] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To assess whether the GnRH-agonist or urinary-hCG ovulation triggers affect oocyte competence in a setting entailing vitrified-warmed euploid blastocyst transfer. METHODS Observational study (April 2013-July 2018) including 2104 patients (1015 and 1089 in the GnRH-a and u-hCG group, respectively) collecting ≥1 cumulus-oocyte-complex (COC) and undergoing ICSI with ejaculated sperm, blastocyst culture, trophectoderm biopsy, comprehensive-chromosome-testing, and vitrified-warmed transfers at a private clinic. The primary outcome measure was the euploid-blastocyst-rate per inseminated oocytes. The secondary outcome measure was the maturation-rate per COCs. Also, the live-birth-rate (LBR) per transfer and the cumulative-live-birth-delivery-rate (CLBdR) among completed cycles were investigated. All data were adjusted for confounders. RESULTS The generalized-linear-model adjusted for maternal age highlighted no difference in the mean euploid-blastocyst-rate per inseminated oocytes in either group. The LBR per transfer was similar: 44% (n=403/915) and 46% (n=280/608) in GnRH-a and hCG, respectively. On the other hand, a difference was reported regarding the CLBdR per oocyte retrieval among completed cycles, with 42% (n=374/898) and 25% (n=258/1034) in the GnRh-a and u-hCG groups, respectively. Nevertheless, this variance was due to a lower maternal age and higher number of inseminated oocytes in the GnRH-a group, and not imputable to the ovulation trigger itself (multivariate-OR=1.3, 95%CI: 0.9-1.6, adjusted p-value=0.1). CONCLUSION GnRH-a trigger is a valid alternative to u-hCG in freeze-all cycles, not only for patients at high risk for OHSS. Such strategy might increase the safety and flexibility of controlled-ovarian-stimulation with no impact on oocyte competence and IVF efficacy.
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El-Damen A, Elkhatib I, Bayram A, Arnanz A, Abdala A, Samir S, Lawrenz B, De Munck N, Fatemi HM. Does blastocyst mitochondrial DNA content affect miscarriage rate in patients undergoing single euploid frozen embryo transfer? J Assist Reprod Genet 2021; 38:595-604. [PMID: 33398514 PMCID: PMC7910391 DOI: 10.1007/s10815-020-02050-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/10/2020] [Indexed: 10/22/2022] Open
Abstract
PURPOSE To determine whether the blastocyst mitochondrial DNA (mtDNA) content is related to the miscarriage rate in patients undergoing single euploid frozen embryo transfer (SEFET). METHODS A total of 355 single euploid frozen embryo transfer cycles were studied retrospectively between April 2017 and December 2018. A trophectoderm biopsy was performed on day 5/6 blastocysts. Post next-generation sequencing (NGS), the mtDNA content was calculated as the ratio of mitochondrial DNA over nuclear DNA, and the association between blastocyst mtDNA content and miscarriage rate was evaluated. RESULT(S) Three hundred fifty-five euploid blastocysts were selected for SEFET in 314 patients with an average age of 33.7 ± 5.6 years; 255 were biopsied on day 5 (71.8%) and 100 on day 6 (28.2%). Frozen embryo transfer (FET) was performed either in a hormone replacement therapy (HRT) cycle (71.8%; n = 255) or in a natural cycle (NC) (28.2%; n = 100). A pregnancy rate of 66.2% (235/355) was obtained with clinical pregnancy and miscarriage rates of 52.4% (n = 186) and 5.6% (n = 20), respectively. There was no significant difference neither between the blastocyst mtDNA content of pregnant and nonpregnant patients (27.7 ± 9.2 vs. 29.4 ± 8.6, P = 0.095) nor between patients with a clinical pregnancy and miscarriage (30.5 ± 9.3 vs. 27.3 ± 9.2, P = 0.136). Multivariate logistic regression analysis showed the same nonsignificant relationship, except for the miscarriage rate and BMI (OR 1.149, 95% CI 1.03-1.28; P = 0.012). CONCLUSION(S) Mitochondrial DNA content is unable to predict the miscarriage of implanted human euploid blastocysts.
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Affiliation(s)
- Ahmed El-Damen
- ART Fertility Clinics, Abu Dhabi, P.O. Box 60202, United Arab Emirates
| | - Ibrahim Elkhatib
- ART Fertility Clinics, Abu Dhabi, P.O. Box 60202, United Arab Emirates
| | - Asina Bayram
- ART Fertility Clinics, Abu Dhabi, P.O. Box 60202, United Arab Emirates
| | - Ana Arnanz
- ART Fertility Clinics, Abu Dhabi, P.O. Box 60202, United Arab Emirates
| | - Andrea Abdala
- ART Fertility Clinics, Abu Dhabi, P.O. Box 60202, United Arab Emirates
| | - Suzan Samir
- ART Fertility Clinics, Abu Dhabi, P.O. Box 60202, United Arab Emirates
| | - Barbara Lawrenz
- ART Fertility Clinics, Abu Dhabi, P.O. Box 60202, United Arab Emirates
- Obstetrical Department, Women’s University Hospital Tübingen, Tübingen, Germany
| | - Neelke De Munck
- ART Fertility Clinics, Abu Dhabi, P.O. Box 60202, United Arab Emirates
| | - Human M. Fatemi
- ART Fertility Clinics, Abu Dhabi, P.O. Box 60202, United Arab Emirates
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Datta AK, Campbell S, Felix N, Singh JSH, Nargund G. Oocyte or embryo number needed to optimize live birth and cumulative live birth rates in mild stimulation IVF cycles. Reprod Biomed Online 2021; 43:223-232. [PMID: 34140227 DOI: 10.1016/j.rbmo.2021.02.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 01/11/2021] [Accepted: 02/18/2021] [Indexed: 11/30/2022]
Abstract
RESEARCH QUESTION How many oocytes or embryos are needed to optimize the live birth rate (LBR) per cycle and cumulative LBR (CLBR) following mild stimulation IVF (MS-IVF) in women with uncompromised ovarian reserve? DESIGN Retrospective analysis of a 4-year database of five fertility centres. The study population included women with normal/high ovarian reserve, who underwent autologous MS-IVF (daily ≤150 IU gonadotrophin) with fresh and subsequent frozen embryo transfer(s) (FET) from surplus embryos. Only the first cycle of each patient was included. Cycles with >150 IU daily average of gonadotrophin were excluded. 'Freeze-all embryo' (FAE) cycles were analysed separately. RESULTS A total of 862 consecutive cycles fulfilled the inclusion criteria; 592 were eligible for fresh embryo transfer, 239 had non-elective 'freeze-all' cycles. Median age (25-75th percentile) of women who had fresh embryo transfer was 35 (32-37) years, median antral follicle count 19 (14-28) and anti-Müllerian hormone 19.2 (13-28.9) pmol/l. LBR/fresh cycle and CLBR inclusive of FAE cycles in the <35, 35-37, 38-39 and 40-42 year age groups were 37.8% and 45.1%, 36.0% and 41.6%, 18.4% and 29.1%, and 8.9% and 18.1%, respectively. The LBR following fresh embryo transfer plateaued after nine oocytes (40.3%) or four embryos (40.8%). The CLBR optimized when 12 oocytes (42.9%) or nine embryos (53.8%) were obtained. The LBR per oocyte peaked in women under 35 years when <5 oocytes were retrieved (11.4%), then declined with age and with higher oocyte yield. There were no cases of severe ovarian hyperstimulation syndrome (OHSS). CONCLUSION Nine oocytes, or four embryos, can optimize fresh transfer cycle LBR in MS-IVF. The CLBR are optimized with 12 oocytes, or nine embryos in predicted normal responders, while safeguarding against OHSS.
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Affiliation(s)
| | | | | | | | - Geeta Nargund
- CREATE Fertility, London, UK; St George's Hospital, London, UK
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