Follicle-stimulating hormone and estradiol levels independently predict the success of assisted reproductive technology treatment

Determinants of Pregnancy Outcomes After Assisted Reproductive Therapy: A Sample From the West Bank, Palestine

Background Infertility is a public health issue with a significant impact on the well-being of affected couples. Aim This paper aims to detect the determinants of pregnancy and their outcome after assisted reproductive therapy (ART) in a sample of Palestinian society. Methods A retrospective observational study was carried out at Razan Medical Center for Infertility. Subjects were assigned into twelve categories based on the type of infertility (primary versus secondary), the cause of infertility, and the treatment modality. Age at marriage, age at presentation, duration of infertility, in addition to regularity of menstruation, were also studied. Biochemical pregnancy was considered the endpoint for the purpose of the analysis. Results We reviewed the files of 459 subjects diagnosed with infertility. 79.74% had primary infertility while 20.26% had secondary. 28.85% were found to be infertile due to anovulation, 2.86% due to endometriosis, 16.74% attributed to male factor, and 3.3% had tubal damage. 13.43% of cases were multifactorial while 34.80% were idiopathic. Four biochemical markers were assessed in our study: thyroid-stimulating hormone (TSH) (x̄=2.32±2.46), luteinizing hormone (x̄=6.71±4.90), follicle-stimulating hormone (FSH) (x̄=6.59±6.11), and human prolactin (x̄=41.88±6.50). The menstrual cycle was regular in 70.58% of subjects, in contrast to 29.41% with irregular cycles. The female mean age at presentation was 22.76±5.58, while their mean age of marriage was 22.76±4. The mean duration of infertility was 3.97±6.87 years. Patients were treated via three modalities - ovarian stimulation (2.2%), intrauterine insemination (29.58%), and intracytoplasmic sperm injection (68.21%) - with a success rate of 51.85%. Of the studied factors, only diagnosis, follicle-stimulating hormone, and treatment modality had a significant impact on the outcome, with p-values of 0.040, 0.003, and <.0.001, respectively. Conclusions There is a strong relationship between diagnosis prior to intervention, level of FSH, and treatment modality and successful outcome of ART.

Current Fertility Preservation Options for Female Patients With Hodgkin Lymphoma

Importance

Many adolescents and young adults diagnosed with Hodgkin lymphoma (HL) experience disease progression requiring high-dose alkylating salvage therapy, which often results in permanent infertility.

Objective

The aim of this report is to discuss fertility preservation options in female patients with consideration of chemotherapeutic agents in HL.

Evidence Acquisition

An electronic literature review was performed utilizing a combination of the terms "Hodgkin lymphoma," "fertility preservation," "ovarian tissue cryopreservation," "oocyte cryopreservation," "embryo cryopreservation," and "gonadotropin-releasing hormone agonist." References and data from identified sources were searched and compiled to complete this review.

Results

Initial treatment of HL is often nonsterilizing; however, salvage therapy and conditioning for stem cell transplantation confer significant gonadotoxicity. Established fertility preservation options for pubertal females include embryo cryopreservation and oocyte cryopreservation. These options are contraindicated within 6 months of receipt of chemotherapy. Ovarian tissue cryopreservation is an option for patients who require salvage therapy within 6 months of first-line therapy.

Conclusions

Timing and choice of fertility preservation techniques depends on planned first-line chemotherapy and response to treatment. In patients initially treated with low-risk chemotherapy, it is reasonable to defer invasive fertility techniques until treatment failure; however, upfront fertility preservation should be considered in patients planning to undergo primary treatment with high-risk therapy.

Anti-mullerian hormone cut-off values for predicting poor ovarian response to exogenous ovarian stimulation in in-vitro fertilization

OBJECTIVES:

(a) To establish the cut-off levels for anti-Mullerian hormone (AMH) in a population of Indian women that would determine poor response. (b) To determine which among the three ie.,: age, follicle stimulating hormone (FSH), or AMH, is the better determinant of ovarian reserve.

STUDY DESIGN:

Prospective observational study.

SETTING:

In vitro fertilization (IVF) unit of a tertiary hospital.

MATERIALS AND METHODS:

The inclusion criterion was all women who presented to the center for in-vitro fertilization/Intracytoplasmic sperm injection (IVF/ICSI). The exclusion criteria were age >45 years, major medical illnesses precluding IVF or pregnancy, FSH more than 20 IU/L, and failure to obtain consent. The interventions including baseline pelvic scan, day 2/3 FSH, luteinizing hormone (LH), estradiol estimations, and AMH measurement on any random day of cycle were done. Subjects underwent IVF according to long agonist or antagonist protocol regimen. Oocyte recovery was correlated with studied variables. The primary outcome measure was the number of oocytes aspirated (OCR). Three categories of ovarian response were defined: poor response, OCR ≤ 3; average response, OCR between 4 and 15; hyperresponse, OCR > 15.

RESULTS:

Of the 198 patients enrolled, poor, average, and hyperresponse were observed in 23%, 63%, and 14% respectively. Correlation coefficient for AMH with ovarian response was r = 0.591. Area under the curve (AUCs) for poor response for AMH, subject's age, and FSH were 0.768, 0.624, and 0.635, respectively. The discriminatory level of AMH for prediction of absolute poor response was 2 pmoL/l, with 98% specificity and 20% sensitivity.

CONCLUSIONS:

AMH fares better than age and FSH in predicting the overall ovarian response and poor response, though it cannot be the absolute predictor of non-responder status. A level of 2 pmol/l is discriminatory for poor response.

Cycle 1 as predictor of assisted reproductive technology treatment outcome over multiple cycles: an analysis of linked cycles from the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System online database

OBJECTIVE

To determine whether the first cycle of assisted reproductive technology (ART) predicts treatment course and outcome.

DESIGN

Retrospective study of linked cycles.

SETTING

Society for Assisted Reproductive Technology Clinic Outcome Reporting System database.

PATIENT(S)

A total of 6,352 ART patients residing or treated in Massachusetts with first treatment cycle in 2004-2005 using fresh, autologous oocytes and no prior ART. Women were categorized by first cycle as follows: Group I, no retrieval; Group II, retrieval, no transfer; Group III, transfer, no embryo cryopreservation; Group IV, transfer plus cryopreservation; and Group V, all embryos cryopreserved.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Cumulative live-birth delivery per woman, use of donor eggs, intracytoplasmic sperm injection (ICSI), or frozen embryo transfers (FET).

RESULT(S)

Groups differed in age, baseline FSH level, prior gravidity, diagnosis, and failure to return for Cycle 2. Live-birth delivery per woman for groups I through V for women with no delivery in Cycle I were 32.1%, 35.9%, 40.1%, 53.4%, and 51.3%, respectively. Groups I and II were more likely to subsequently use donor eggs (14.5% and 10.9%). Group II had the highest use of ICSI (73.3%); Group III had the lowest use of FET (8.9%).

CONCLUSION(S)

Course of treatment in the first ART cycle is related to different cumulative live-birth delivery rates and eventual use of donor egg, ICSI, and FET.

Impact of GnRH ovarian stimulation protocols on intracytoplasmic sperm injection outcomes

BACKGROUND

Although a large number of studies have been conducted in relation to ovarian response and pregnancy after GnRH agonist and GnRH antagonist controlled ovarian hyperstimulation protocols, most of them used single or combinations of a few predictive factors, and none included the stimulation protocol in the multivariable analysis. The present study was thus primarily designed to investigate the predictive value of the stimulation protocol and to analyze the possible relationships between stimulation protocols and treatment outcomes after adjusting for a large set of variables that potentially affect reproductive outcomes. Factors related to pregnancy achievement and predictive of the number of oocytes retrieved and high quality of the embryos obtained were also analyzed.

METHODS

To analyze the impact of GnRH ovarian stimulation protocols on the independent predictors of ovarian response, high quality embryos and clinical pregnancy, two groups out of 278 ICSI treatment cycles were compared prospectively, 123 with a GnRH agonist and 155 with a GnRH antagonist, with multivariable analysis assessing outcomes after adjusting for a large set of variables.

RESULTS

Antagonists were significantly associated with lower length and total dose of GnRH, lower length of rFSH, and higher numbers of oocytes and high quality embryos, whereas the agonist presented a higher fertilization rate and probability of pregnancy. Significant predictors of retrieved oocytes and high quality embryos were the antagonist protocol, lower female age, lower serum levels of basal FSH and higher total number of antral follicles. Significant predictors of clinical pregnancy were the agonist protocol, reduced number of attempts, increased endometrial thickness and lower female age. The probability of pregnancy increased until 30 years-old, with a decline after that age and with a sharp decline after 40 years-old.

CONCLUSION

The models found suggest that not only the protocol but also factors as female age, basal FSH, antral follicles, number of attempts and endometrial thickness should be analyzed for counselling patients undergoing an ICSI treatment.

Optimizing the number of cleavage stage embryos to transfer on day 3 in women 38 years of age and older: a Society for Assisted Reproductive Technology database study

OBJECTIVE

To determine the optimal number of day 3 embryos to transfer in women >or=38 years by conducting an evidence-based evaluation.

DESIGN

Retrospective analysis of 2000-2004 national SART data.

SETTING

National writing group.

PATIENT(S)

A total of 36,103 day 3 embryo transfers in women >or=38 years undergoing their first assisted reproductive technology cycle.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Logistic regression was used to model the probability of pregnancy, delivery, and multiple births (twin or high order) based on age- and cycle-specific parameters.

RESULT(S)

Pregnancy rates, delivery rates, and multiple rates increased up to transfer of three embryos in 38-year-olds and four in 39-year-olds; beyond this number, only multiple rates increased. In women >or=40 years, delivery rates and multiple rates climbed steadily with increasing numbers transferred. Multivariate analysis confirmed the statistically significant effect of age, number of oocytes retrieved, and embryo cryopreservation on delivery and multiple rates. Maximum FSH level was not an independent predictor by multivariate analysis. Use of intracytoplasmic sperm injection was associated with lowered delivery rate.

CONCLUSION(S)

No more than three or four embryos should be transferred in 38- and 39-year-olds, respectively, whereas up to five embryos could be transferred in >or=40-year-olds. Numbers of embryos to transfer should be adjusted according to number of oocytes retrieved and availability of excess embryos for cryopreservation.

Assisted reproductive technology practice patterns and the impact of embryo transfer guidelines in the United States

OBJECTIVE

[1] To evaluate trends in number of embryos transferred and resultant high-order multiple (HOM) pregnancy rates by Society for Assisted Reproductive Technology (SART)-member clinics between 1996 and 2003 and [2] to relate these practice patterns and outcomes to clinic compliance with SART-American Society for Reproductive Medicine (ASRM) embryo transfer guidelines.

DESIGN

Retrospective.

SETTING

Society for Assisted Reproductive Technology-member fertility centers in the United States.

PATIENT(S)

Five hundred thirty-six thousand, five hundred twenty-four fresh, nondonor IVF cycles.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Number of embryos transferred; pregnancy rates; implantation rates; and proportion of singleton, twin, and HOM pregnancies.

RESULT(S)

The number of embryos transferred declined each year. High-order multiple pregnancy rates also declined, whereas the twin rates remained stable. The most pronounced declines in number transferred occurred immediately after publication of SART-ASRM embryo transfer guidelines. After stratifying clinics according to mean and modal number of embryos transferred, clinics transferring the fewest embryos in women <35 years of age had the highest mean implantation and pregnancy rates. Furthermore, the percentage of clinics transferring two embryos to a majority of women <35 years of age increased from 3.3% in 1996 to 49.9% in 2003.

CONCLUSION(S)

The implementation of SART-ASRM embryo transfer guidelines is associated with significant reductions in the number of embryos being transferred, along with reductions of HOM pregnancies. Initiatives to further reduce twin pregnancies and encourage singleton gestation outcomes are outlined.

Quality of reporting of test accuracy studies in reproductive medicine: impact of the Standards for Reporting of Diagnostic Accuracy (STARD) initiative

OBJECTIVE

To evaluate the extent to which test accuracy studies published in two leading reproductive medicine journals in the years 1999 and 2004 adhered to the Standards for Reporting of Diagnostic Accuracy (STARD) initiative parameters, and to explore whether the introduction of the STARD statement has led to an improved quality of reporting.

DESIGN

Structured literature search. Articles that reported on the diagnostic performance of a test in comparison with a reference standard were eligible for inclusion. For each article we scored how well the 25 items of the STARD checklist were reported. These items deal with the study question, study participants, study design, test methods, reference standard, statistical methods, reporting of results, and conclusions. We calculated the total number of reported STARD items per article, summary scores for each STARD item, and the average number of reported STARD items per publication year.

SETTING

Not applicable.

PATIENT(S)

Not applicable.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Quality of reporting.

RESULT(S)

We found 24 studies reporting on test accuracy in reproductive medicine in 1999 and 27 studies in 2004. The mean number of reported STARD items for articles published in 1999 was 12.1 +/- 3.3 (range 6.5-20) and 12.4 +/- 3.2 (range 7-17.5) in 2004, after publication of the STARD statement. Overall, less than half of the studies reported adequately on 50% or more of the STARD items. The reporting of individual items showed a wide variation. There was no significant improvement in mean number of reported items for the articles published after the introduction of the STARD statement.

CONCLUSION(S)

Authors of test accuracy studies in the two leading fertility journals poorly report the design, conduct, methodology, and statistical analysis of their study. Strict adherence to the STARD guidelines should be encouraged.

Preconception care and treatment with assisted reproductive technologies

Couples with fertility problems seeking treatment with assisted reproductive technologies (ART) such as in vitro fertilization should receive preconception counseling on all factors that are provided when counseling patients without fertility problems. Additional counseling should address success rates and possible risks from ART therapies. Success rates from ART are improving, with the highest live birth rates averaging about 40% per cycle among women less than 35 years old. A woman's age lowers the chance of achieving a live birth, as do smoking, obesity, and infertility diagnoses such as hydrosalpinx, uterine leiomyoma, or male factor infertility. Singletons conceived with ART may have lower birth weights. Animal studies suggest that genetic imprinting disorders may be induced by certain embryo culture conditions. The major risk from ovarian stimulation is multiple gestation. About one-third of live-birth deliveries from ART have more than one infant, and twins represent 85% of these multiple-birth children. There are more complications in multiple gestation pregnancies, infants are more likely to be born preterm and with other health problems, and families caring for multiples experience more stress. Transferring fewer embryos per cycle reduces the multiple birth rate from ART, but the patient may have to pay for additional cycles of ART because of a lower likelihood of pregnancy.