Pituitary suppression before frozen embryo transfer is beneficial for patients suffering from idiopathic repeated implantation failure

Effect of GnRH agonist down-regulation combined with hormone replacement treatment on reproductive outcomes of frozen blastocyst transfer cycles in women of different ages

Objective

To investigate the effect of GnRH agonist (GnRH-a) down-regulation prior to hormone replacement treatment (HRT) to prepare the endometrium in frozen embryo transfer (FET) cycles in women of different ages.

Methods

This was a retrospective study, and after excluding patients with adenomyosis, endometriosis, severe endometrial adhesions, polycystic ovary syndrome (PCOS), and repeated embryo implantation failures, a total of 4,091 HRT cycles were collected. Patients were divided into group A (<35 years old) and group B (≥35 years old), and each group was further divided into HRT and GnRHa-HRT groups. The clinical outcomes were compared between groups.

Results

There was no statistically significant difference in clinical outcomes between the HRT and GnRHa-HRT groups among women aged <35 years. In women of advanced age, higher rates of clinical pregnancy and live birth were seen in the GnRHa-HRT group. Logistic regression analysis showed that female age and number of embryos transferred influenced the live birth rate in FET cycles, and in women aged ≥ 35 years, the use of GnRH-a down-regulation prior to HRT improved pregnancy outcomes.

Conclusions

In elderly woman without adenomyosis, endometriosis, PCOS, severe uterine adhesions, and RIF, hormone replacement treatment with GnRH agonist for pituitary suppression can improve the live birth rate of FET cycles.

Comparison of the efficacy of depot GnRH agonist protocol and the GnRH antagonist protocol in patients with repeated IVF failure: a retrospective cohort study

The aims of the research were (i) to compare the clinical outcome of IVF using follicular-phase depot gonadotropin-releasing hormone (GnRH) agonist (depot agonist) protocol and GnRH antagonist protocol in patients with repeated IVF failure (RIF), (ii) to discover the optimal ovarian stimulation protocol for this group of low prognosis patients. 801 RIF patients with normal ovarian reserve receiving in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) were included in this retrospective study. Among them, 492 patients were treated with the depot agonist protocol, and the remaining 309 patients with the antagonist protocol. Multivariable logistic regression analysis was used to find the predictor(s) of the chance of live birth. Higher live birth rate (LBR) and clinical pregnancy rate (CPR) in fresh embryo transfer (ET) cycles were associated with the use of depot agonist compared with the antagonist protocols (44.81% vs. 27.27%, 54.64% vs. 34.93%, respectively; both p < 0.01) and depot agonist protocol was a strong predictor of live birth (OR = 2.182, 95% CI 1.355-3.514, p < 0.01). The CPR in thawed ET cycles was not significantly different between the two groups (38.12% vs. 45.26%, p > 0.05). A higher cumulative live birth rate (CLBR) was achieved in the depot agonist group (46.59% vs. 35.21%, p < 0.01). Beneficial endometrial receptivity in the depot agonist protocol contributed to a higher LBR in fresh ET cycles, rendering this protocol the preferred option in the treatment of RIF patients.

Preparation of the endometrium for frozen embryo transfer: an update on clinical practices

Over the past decade, the application of frozen-thawed embryo transfer treatment cycles has increased substantially. Hormone replacement therapy and the natural cycle are two popular methods for preparing the endometrium. Hormone replacement therapy is now used at the discretion of the doctors because it is easy to coordinate the timing of embryo thawing and transfer with the schedules of the in-vitro fertilization lab, the treating doctors, and the patient. However, current results suggest that establishing a pregnancy in the absence of a corpus luteum as a result of anovulation may pose significant maternal and fetal risks. Therefore, a 'back to nature' approach that advocates an expanded use of natural cycle FET in ovulatory women has been suggested. Currently, there is increasing interest in how the method of endometrial preparation may influence frozen embryo transfer outcomes specifically, especially when it comes to details such as different types of ovulation monitoring and different luteal support in natural cycles, and the ideal exogenous hormone administration route as well as the endocrine monitoring in hormone replacement cycles. In addition to improving implantation rates and ensuring the safety of the fetus, addressing these points will allow for individualized endometrial preparation, also as few cycles as possible would be canceled.

STROBE-GnRHa pretreatment in frozen-embryo transfer cycles improves clinical outcomes for patients with persistent thin endometrium: A case-control study

The well-prepared endometrium with appropriate thickness plays a critical role in successful embryo implantation. The thin endometrium is the main factor of frozen-embryo transfer (FET), resulting in the failure of implantation undergoing FET. Hormone treatment is suggested to improve endometrium thickness; however, among the larger numbers of cases, it cannot reach the sufficient thickness, which leads to a high cancelation rate of embryo transfer as well as waste high-quality embryos. Thus, it increases the burden to patients in both economic and psychological perspectives. We performed a retrospective observational study, which was composed with 2 cohorts, either with the conventional hormone replacement therapy (HRT) protocol or HRT with gonadotrophin-releasing hormone agonist (GnRHa) pretreatment to prepare the endometrium before FET. The measurements of endometrium thickness, hormone level, transfer cycle cancelation rate, pregnancy rate, and implantation rate were retrieved from the medical records during the routine clinic visits until 1 month after embryo transfer. The comparisons between 2 cohorts were performed by t-test or Mann-Whitney U test depending on the different attributions of data. In total, 49 cycles were under HRT with GnRHa pretreatment and 84 cycles were under the conventional HRT protocol. HRT with GnRHa pretreatment group improved the endometrial thickness (8.13 ± 1.79 vs 7.51 ± 1.45, P = .031), decreased the transfer cancelation rate (P = .003), and increased clinical pregnancy rate and implantation rate significantly (both P = .001). Additionally, luteinizing hormone level in pretreatment group was consistently lower than conventional HRT group (P < .05). Our study revealed HRT with GnRHa pretreatment efficiently improved the endometrial thickness, therefore, decreased the FET cycle cancelation. It also elevated the embryo implantation rate and clinical pregnancy rate by improving endometrial receptivity.

Recurrent implantation failure and sexual function in infertile Iranian women: a comparative cross sectional study

Background

Recurrent implantation failure (RIF) which means failing to implant after two or more high-quality embryo transfer cycles, affects 3% to 5% of women worldwide. The aim of this study was to assess the relationship between recurrent implantation failure and sexual function in infertile Iranian women.

Methods

This was a comparative cross-sectional study on 180 infertile Iranian women (90 infertile women with recurrent implantation failure and 90 infertile women who did not start infertility treatment). A demographic questionnaire and the Female Sexual Function Index were used for data collection. Data were analyzed using Chi-square, independent t-test, and multiple linear regression.

Results

The mean scores of different domains of sexual function (desire, lubrication, arousal, orgasm, pain, and satisfaction) were significantly lower in the group with RIF compared to the group without RIF. The total score of sexual function was significantly lower in the RIF group compared with the group without RIF (23.11 ± 2.24, vs. 25.99 ± 2.35, p < 0.001). The overall sexual function scores in women with RIF were 2.65 units lower than women without RIF (p < 0.001).

Conclusion

The results of this study showed that women with RIF had significantly lower sexual function than that in women without RIF. Therefore, sexual function issues should be treated as an important component of comprehensive care. This study did not measure the impact of economic factors on sexual function, however, the majority of the sample were classified as having weak or moderate economic status and this, along with the high cost of infertility treatments, could potentially have played a role in the participants' experience. This relationship will need to be investigated in future research.

Recurrent implantation failure (RIF) means inability to implant after two or more high-quality embryo transfer cycles. The aim of this study was to assess the relationship between recurrent implantation failure and sexual function in infertile Iranian women. In this study, 180 infertile Iranian women (including 90 infertile women with recurrent implantation failure and 90 infertile women with no implantation failure) were recruited. A demographic questionnaire and the Female Sexual Function Index were used for data collection. The mean scores of different domains of sexual function (desire, lubrication, arousal, orgasm, pain, and satisfaction) were significantly lower in the group with recurrent implantation failure compared to the group without. The overall sexual function scores in the RIF group were 2.65 units lower than those of women without RIF. Women experiencing recurrent implantation failure may be at a particular risk of reduced sexual function. Therefore, sexual function issues should be treated as an important component of comprehensive care.

Gonadotropin-releasing hormone agonist downregulation combined with hormone replacement therapy improves the reproductive outcome in frozen-thawed embryo transfer cycles for patients of advanced reproductive age with idiopathic recurrent implantation failure

BACKGROUND

To determine whether gonadotropin-releasing hormone (GnRH) agonist downregulation combined with hormone replacement therapy (HRT) can improve the reproductive outcomes in frozen-thawed embryo transfer cycles for older patients (aged 36-43 years) with idiopathic recurrent implantation failure (RIF).

METHODS

This retrospective cohort study involved 549 older patients undergoing their third cleavage-stage embryo or blastocyst transfer over a 5-year period (January 2015-December 2020) at Northwest Women's and Children's Hospital after in vitro fertilization/intracytoplasmic sperm injection cycles. Patients with known endometriosis or adenomyosis were excluded from the study. The patients were divided into three groups according to the endometrial preparation protocol: the natural cycle (NC) group (n = 65), the HRT group (n = 194), and the GnRH agonist downregulation combined with HRT cycle (GnRH agonist-HRT) group (n = 290). The primary outcome was the live birth rate, and the secondary outcomes were the clinical pregnancy, miscarriage, and ongoing pregnancy rates.

RESULTS

The live birth rate in the GnRH agonist-HRT group (36.55%) was higher than that in the HRT group (22.16%) and NC group (16.92%) (P < 0.0001). Similarly, a logistic regression model adjusting for potential confounders showed that the live birth rate was higher in the GnRH agonist-HRT group than in the HRT group (odds ratio, 0.594; 95% confidence interval, 0.381-0.926; P = 0.021) and NC group (odds ratio, 0.380; 95% confidence interval, 0.181-0.796; P = 0.010).

CONCLUSIONS

The GnRH agonist-HRT protocol improves the live birth rate in frozen-thawed embryo transfer cycles for patients of advanced reproductive age with RIF. We hypothesize that the GnRH agonist-HRT protocol enhances implantation-related factors and promotes optimal endometrial receptivity, leading to an improved live birth rate. These findings are also useful for further investigating the underlying mechanism of the GnRH agonist-HRT protocol in improving the reproductive outcomes for patients of advanced reproductive age with RIF.

TRIAL REGISTRATION

This research protocol was approved by the hospital institutional ethics committee (No. 2021002).

Transcriptome analysis of eutopic endometrium in adenomyosis after GnRH agonist treatment

BACKGROUND

Adenomyosis is a chronic gynecological disease characterized by invasion of the uterine endometrium into the muscle layer. In assisted reproductive technology (ART), gonadotropin-releasing hormone agonist (GnRHa) is often used to improve pregnancy rates in patients with adenomyosis, but the underlying mechanisms are poorly understood.

METHODS

Eutopic endometrial specimens were collected from patients with adenomyosis before and after GnRHa treatment in the midsecretory phase. RNA sequencing (RNA-Seq) of these specimens was performed for transcriptome analysis. The differentially expressed genes (DEGs) of interest were confirmed by real-time PCR and immunohistochemistry.

RESULTS

A total of 132 DEGs were identified in the endometrium of patients with adenomyosis after GnRHa treatment compared with the control group. Bioinformatics analysis predicted that immune system-associated signal transduction changed significantly after GnRHa treatment. Chemokine (C-C motif) ligand 21 (CCL21) was found to be highly expressed in the eutopic endometrium after GnRHa treatment, which may be involved in the improvement of endometrial receptivity in adenomyosis.

CONCLUSION

This study suggests that molecular regulation related to immune system-associated signal transduction is an important mechanism of GnRHa treatment in adenomyosis. Immunoreactive CCL21 is thought to regulate inflammatory events and participate in endometrial receptivity in adenomyosis.

Functional Ovarian Cysts in Artificial Frozen-Thawed Embryo Transfer Cycles With Depot Gonadotropin-Releasing Hormone Agonist

OBJECTIVES

To investigate the incidence of functional ovarian cysts, its influence on clinical rates, and proper management after depot gonadotropin-releasing hormone (GnRH) agonist pretreatment in artificial frozen-thawed embryo transfer cycles (AC-FET).

METHODS

This retrospective cohort study involved 3375 AC-FET cycles with follicular-phase depot GnRH agonist administration between January 2017 and December 2020. Subjects were divided into a study group (cycles with cyst formation) and a control group (cycles without cyst formation). The study group was matched by propensity scoring matching with the control group at a ratio of 1:2. For patients with ovarian cyst formation, two major managements were used: a conservative approach (i.e., expectant treatment) and a drug approach (i.e., continued agonist administration). The primary outcome was live birth rate (LBR).

RESULTS

The incidence of functional ovarian cysts following pituitary downregulation is 10.1% (341/3375). The study group exhibited a LBR similar to the control group (54.5% vs. 50.1%, adjusted odds ratio [aOR] 1.17, 95% confidence interval [CI] 0.88-1.56, P = 0.274). Patients with a lower body mass index and anti-Müllerian hormone, and a higher basal estradiol level were more susceptible to developing functional ovarian cysts. The LBR decreased after the drug approach compared with the conservative approach, but not significantly (aOR 0.63, 95% CI 0.35-1.14, P = 0.125). Following the conservative approach, cycles arrived at live births had a significantly shorter duration from the detection of functional cysts to the start of endometrium preparation (15.7 ± 5.1 days vs. 17.4 ± 5.3 days, P = 0.009) and a significantly higher proportion of ovarian cysts on the initial day of exogenous hormone supplementation (51.4% vs. 30.3%, P = 0.001). After controlling for all confounders, the differences remained statistically significant.

CONCLUSIONS

It is unnecessary to cancel cycles that experience functional ovarian cyst formation. Conservative management and further agonist suppression protocol had similar pregnancy rates. However, a conservative approach was recommended due to its lower cost and fewer side effects. Our findings support a shorter waiting period when choosing the conservative protocol.

Hormonal Replacement Treatment for Frozen-Thawed Embryo Transfer With or Without GnRH Agonist Pretreatment: A Retrospective Cohort Study Stratified by Times of Embryo Implantation Failures

OBJECTIVE

To evaluate the efficacy of the long-acting gonadotropin-releasing hormone agonist (GnRH-a) administration before hormone replacement treatment for frozen-thawed embryo transfer in women with different times of embryo implantation failures.

METHODS

A retrospective cohort study was performed between January 2015 and December 2019. A total of 9263 women who underwent frozen-thawed embryo transfer were included in the study. The study is divided into three parts based on the times of embryo implantation failures. The sample sizes were 4611 for no implantation failure, 3565 for one failure and 1087 for multiple failures. Two endometrium preparation protocols, HRT and HRT with GnRH-a pretreatment (G-HRT), were compared. Confounding factors were treated by propensity score matching and generalized estimation equation.

RESULTS

For women with no failure of embryo implantation, the live birth rate was not statistically different when they underwent HRT and G-HRT (HRT: 42.75% [498/1165], G-HRT: 45.24% [527/1165], P=0.2261). Similar outcome also appeared in women with one failure of embryo implantation (HRT: 47.22% [535/1133], G-HRT: 50.31% [570/1131], P=0.1413). For women with multiple failures of embryo implantation, the live birth rate was significantly difference (HRT: 38.74% [117/302], G-HRT: 45.48% [357/785], P=0.0449). When stratified by age, the live birth rate is similar for women older than 37 years. Generalized estimation equation showed that GnRH agonist pretreatment was independently associated with the live birth rate for women with multiple failures (adjust OR: 1.5, 95%CI: [1.12-2.00]).

CONCLUSION

For women with no/one failure of embryo implantation, the live birth rate is similar between HRT and G-HRT protocols. For women with multiple failure of embryo implantation, GnRH agonist pretreatment is beneficial to raise the live birth rate.

Long-term pituitary downregulation before frozen embryo transfer improves clinical outcomes in women positive for serum autoantibodies

OBJECTIVE

Autoantibodies are associated with worse outcomes in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI), including increasing miscarriage rate, lowering pregnancy rate, and lowering delivery rate. However, little is known about improving IVF/ICSI outcomes for autoantibody-positive women, especially in frozen-thawed embryo transfer (FET) cycles. This study aimed to investigate whether pituitary suppression before FET improves the clinical pregnancy rate (CPR) and live birth rate (LBR) for IVF/ICSI women positive for serum autoantibodies.

STUDY DESIGN

A total of 181 infertile women positive for serum autoantibodies were recruited, including 65 women receiving GnRHa and hormone replacement therapy protocols (G-HRT group) and 116 women using modified natural cycles (MNC)/mild stimulated cycles (MSC) as FET protocols (MNC/MSC group). The outcomes were compared between two groups, including CPR, implantation rate (IR), miscarriage rate (MR), ongoing pregnancy rate (OPR), LBR, and gestational age (GA). The primary outcome of the study was CPR.

RESULTS

CPR, OPR, and LBR per embryo transferred in the G-HRT groups were significantly higher than those in the MNC/MSC group. No statistically significant differences were observed in the IR and MR. The CPR, IR, MR, OPR, and LBR was 72.23%, 64.00%, 12.77%, 63.07%, and 63.07% in the G-HRT group, respectively, while that was 56.90%, 53.07%, 10.60%, 50.00%, and 50.00% in the MNC/MSC group, respectively. After adjusting for partial potential confounding factors using multiple logistic regression, the type of endometrial preparation is the factor independently associated with enhanced CPR (OR = 0.48, 95%CI: 0.24-0.96, P = 0.039).

CONCLUSIONS

The current study showed that prior long-term GnRHa suppression could benefit patients with high serum autoantibody levels during IVF/ICSI FET cycles.

Endometrial preparation using gonadotropin-releasing hormone agonist prior to frozen-thawed embryo transfer in women with repeated implantation failure: An RCT

Background

Preparation of endometrial thickness in frozen-thawed embryo transfer (FET) is extremely important, particularly in repeated implantation failure (RIF) patients.

Objective

This study aimed to investigate the clinical outcomes of FET cycles among RIF women, based on the effects of administering gonadotropin-releasing hormone (GnRH) agonist prior to estrogen-progesterone preparation of the endometrium.

Materials and Methods

In this randomized clinical trial, 67 infertile women who were candidates for FET were divided into two groups: A) case group (n = 34), treated with GnRH agonist prior to endometrial preparation and B) control group (n = 33), which received the routine protocol. (6 mg daily estradiol started from second day) The clinical outcomes) including chemical and clinical pregnancy, in addition to implantation rates, were compared between the two groups.

Results

The results showed no significant differences in women's age (p = 0.558), duration (p = 0.540), type (p = 0.562), and cause of infertility (p = 0.699). Regarding pregnancy and implantation rates, there was a trend toward an increase in the case group; however, differences were not statistically significant.

Conclusion

Although our results showed no significant differences between groups. Because there are trends to better results in case group larger sample size may show significant difference.

Effect of GnRH agonist and letrozole treatment in women with recurrent implantation failure

OBJECTIVE

To compare the influence of dual suppression with the use of GnRH agonist plus aromatase inhibitor compared with suppression with the use of GnRH agonist alone or no suppression at all in patients with idiopathic recurrent implantation failure (RIF).

DESIGN

Retrospective cohort study.

SETTING

University-affiliated reproductive center.

PATIENT(S)

A total of 523 infertile women who failed two blastocyst transfers underwent a third frozen blastocyst transfer. Women with known endometriosis were excluded.

INTERVENTION(S)

A total of 204 subjects were not pretreated, 143 received 2 months of GnRH agonist (3.75 mg intramuscular leuprolide acetate monthly) only, and 176 received GnRH agonist and aromatase inhibitor (5 mg oral letrozole daily for 60 days). Demographic and stimulation information was collected and cycle outcomes reported.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rates.

RESULT(S)

Age, antral follicle count, basal FSH levels, duration of infertility, previous pregnancies, and full-term deliveries were similar (P>.05). Clinical pregnancy rates were higher among women who received GnRH agonist plus letrozole compared with women who received GnRH agonist only or women without pretreatment (63%, 42%, and 40%, respectively; P<.0001). Live birth rates were higher among women who received GnRH agonist plus letrozole compared with the other groups (56%, 36%, and 34%; P<.0001). No differences in pregnancy outcomes were noted between patients who did not receive pretreatment and those in the GnRH agonist only group.

CONCLUSION(S)

In patients with RIF, treatment with a GnRH agonist plus letrozole may improve live birth rates in subsequent cycles. We hypothesize that this improvement is due to alterations in the endometrium receptivity or treatment of undiagnosed endometriosis.

Management of recurrent implantation failure by gonadotropin-releasing hormone agonist and aromatase inhibitor suppression, in women without evidence of endometriosis

Endometriosis is common among those with infertility, although many cases go undiagnosed. This study was performed to determine whether empiric treatment with two months of depo-leuprolide 3.75 mg monthly (dep-GnRH-ag) and letrozole 5 mg daily improves pregnancy outcomes in patients with at least two unexplained failed embryo transfers (ETs) but without a previous diagnosis of endometriosis. A retrospective cohort study was performed with subjects who failed at least two good quality ET. The study excluded women with a known history of endometriosis or ovarian cysts (possible endometriomas). Subjects (N = 38) were treated with dep-GnRH-ag and letrozole pre-cycle. Matched women (N = 37) who did not receive either pretreatment served as a control group. Data were compared by non-paired T-tests and multivariate logistic regression to control for confounding effects. Demographic data, hormonal profiles, and ovarian reserve parameters were similar between the two groups. The treated group had failed more embryo transfers (3.5 ± 1.7 vs. 2.0 ± 1.3, p = .01) than the controls. When adjusting for the number of MII oocytes collected, number of blastocysts developed and number of blastocysts transferred, there were more pregnancies (24/38 vs. 11/37, p = .02) and ongoing pregnancies (18/38 vs. 9/37, p = .03) in the treated group. Patients with multiple unexplained failed ET may have undiagnosed endometriosis and may benefit from pretreatment with dep-GnRH-ag and letrozole. These results would benefit from being subjected to a randomized prospective study.