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Berdin A, Bellaïche K, El Hachem H, Vielle B, Legendre G, Descamps P, May-Panloup P, Prevost S, Bouet PE. Comparison of two cancellation strategies to lower the risk of multiple pregnancies in gonadotropin stimulated intrauterine insemination cycles. Int J Gynaecol Obstet 2024. [PMID: 38425230 DOI: 10.1002/ijgo.15449] [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: 10/05/2023] [Revised: 01/09/2024] [Accepted: 02/12/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVE To compare two cancellation policies in controlled ovarian stimulation-intrauterine insemination (COS-IUI) cycles to lower the risk of multiple pregnancies (MP). DESIGN We performed a bicentric retrospective cohort study in two academic medical centers: Angers (group A) and Besançon (group B) University Hospitals. We included 7056 COS-IUI cycles between 2011 and 2019. In group A, cancellation strategy was based on an algorithm taking into account the woman's age, the serum estradiol level, and the number of follicles of 14 mm or greater on ovulation trigger day. In group B, cancellation strategy was case-by-case and physician-dependent, based on the woman's age, number of follicles of 15 mm or greater, and the previous number of failed COS-IUI cycles, without any predefined cut-off. Our main outcome measures were the MP rate (MPR) and the live-birth rate (LBR). RESULTS We included 884 clinical pregnancies (790 singletons, 86 twins, and 8 triplets) obtained from 6582 COS-IUI cycles. MPR was significantly lower in group A compared with group B (8.1% vs 13.3%, P = 0.01), but LBR were comparable (10.8% vs 11.8%, P = 0.19). Multivariate logistic regression found the following to be risk factors for MP: the "cancellation strategy" effect (adjusted odds ratio [aOR] 1.63, 95% confidence interval [CI] 1.02-2.60) and the number of follicles of 14 mm or greater (aOR 1.39, 95% CI 1.16-1.66). Cycle cancellation rate for excessive response was significantly lower in group A compared with group B (1.3% vs 2.4%, P < 0.001). CONCLUSIONS The use of an algorithm based on the woman's age, serum estradiol level and number of follicles of at least 14 mm on trigger day allows the MPR to be reduced without impacting the LBR.
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Affiliation(s)
- Aurélie Berdin
- Department of Reproductive Medicine, Besançon University Hospital, Besançon, France
| | - Kevin Bellaïche
- Department of Reproductive Medicine, Angers University Hospital, Angers, France
| | - Hady El Hachem
- Department of Obstetrics and Gynecology, Lebanese American University Medical Center, Beirut, Lebanon
| | - Bruno Vielle
- Clinical Research Center, Angers University Hospital, Angers, France
| | - Guillaume Legendre
- Department of Reproductive Medicine, Angers University Hospital, Angers, France
| | - Philippe Descamps
- Department of Reproductive Medicine, Angers University Hospital, Angers, France
| | - Pascale May-Panloup
- Department of Reproductive Medicine, Angers University Hospital, Angers, France
| | - Sarah Prevost
- Department of Reproductive Medicine, Besançon University Hospital, Besançon, France
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The role of peak serum estradiol level in the prevention of multiple pregnancies in gonadotropin stimulated intrauterine insemination cycles. Sci Rep 2022; 12:19554. [PMID: 36379965 PMCID: PMC9666543 DOI: 10.1038/s41598-022-23470-9] [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: 03/16/2022] [Accepted: 11/01/2022] [Indexed: 11/16/2022] Open
Abstract
The objective was to assess whether the measurement of serum estradiol (E2) level on trigger day in controlled ovarian stimulation with intrauterine insemination (COS-IUI) cycles helps lower the multiple pregnancy (MP) rate. We performed a unicentric observational study. We included all patients who underwent COS-IUI and had a subsequent clinical pregnancy (CP) between 2011 and 2019. Our main outcome measure was the area under Receiver-Operating Characteristic (ROC) curve. We included 455 clinical pregnancies (CP) obtained from 3387 COS-IUI cycles: 418 singletons, 35 twins, and 2 triplets. The CP, MP, and live birth rates were respectively 13.4%, 8.1% and 10.8%. The area under ROC curve for peak serum E2 was 0.60 (0.52-0.69). The mean E2 level was comparable between singletons and MP (260.1 ± 156.1 pg/mL vs. 293.0 ± 133.4 pg/mL, p = 0.21, respectively). Univariate and multivariate logistic regression analysis showed that E2 level was not predictive of MP rate (aOR: 1.13 (0.93-1.37) and 1.06 (0.85-1.32), respectively). Our study shows that, when strict cancelation criteria based on the woman's age and follicular response on ultrasound are applied, the measurement of peak serum E2 levels does not help reduce the risk of MP in COS-IUI cycles.
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Bae B. Ovulation Induction in the Primary Gynecology Setting. PHYSICIAN ASSISTANT CLINICS 2022. [DOI: 10.1016/j.cpha.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Prevention of multiple pregnancies in gonadotropin-insemination cycles. Curr Opin Obstet Gynecol 2022; 34:101-106. [PMID: 35645007 DOI: 10.1097/gco.0000000000000777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Although elective single embryo transfer has significantly reduced, the rate of multiple pregnancy in IVF cycles, this rate is still relatively high in gonadotropin-insemination cycles. Patients who fail to ovulate or to conceive with oral agents and have constraints for IVF are usually candidates for gonadotropin injections. The current review article provides an up-to-date summation of the different strategies that can be adopted to reduce the risk of multiple pregnancies in gonadotropin-stimulated intrauterine insemination cycles. RECENT FINDINGS Gonadotropin-insemination treatments should be used judiciously by experienced providers. One should always start with the lowest effective gonadotropin dose (∼37.5 IU), monitor closely the ovarian response, and consider cycle cancellation or conversion to IVF whenever a high response is encountered. Therefore, every infertility practice should define its own cancellation and 'rescue IVF' criteria depending on the number of mature ovarian follicles and the age of the female partner. SUMMARY These preventive measures amongst others should mitigate the risk of multiple pregnancies that can arise from gonadotropin-insemination cycles.
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Socolov R, Akad M, Păvăleanu M, Popovici D, Ciuhodaru M, Covali R, Akad F, Păvăleanu I. The Rare Case of a COVID-19 Pregnant Patient with Quadruplets and Postpartum Severe Pneumonia. Case Report and Review of the Literature. Medicina (B Aires) 2021; 57:medicina57111186. [PMID: 34833404 PMCID: PMC8624501 DOI: 10.3390/medicina57111186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 10/22/2021] [Accepted: 10/26/2021] [Indexed: 12/24/2022] Open
Abstract
Background and Objectives: The multiple pregnancies associated with COVID-19 is a new and difficult condition to manage. The prognosis for rapid deterioration after the cesarean delivery is difficult to assess and needs close interdisciplinary follow-up due to pregnancy and postpartum-related changes. Materials and Methods: We report the case of a 37-year-old primigesta primipara patient who was admitted to “Elena Doamna” Clinical Hospital of Obstetrics and Gynecology at 33 weeks and 3 days of gestation with high-grade multiple pregnancies (triplets) for threatened premature birth associated with COVID-19. The patient had a history of surgically corrected atrial septal defect during childhood and currently is known to have paroxysmal supraventricular tachycardia. Tocolysis was ineffective and the decision to perform a cesarean operation was made. The diagnosis was established: primigesta, primipara, at 34 weeks of gestation, high-grade multiple pregnancy with triplets, intact membranes, threatened premature birth, surgically corrected atrial septal defect, paroxysmal supraventricular tachycardia, infection with COVID-19. The patient underwent a cesarean intervention and treatment for COVID-19 pneumonia. The intervention took place at 33 weeks and 4 days of gestation resulting in four newborns with weights between 1400 g and 1820 g and Apgar scores between 6–8. All newborns were transferred to a third-degree Neonatology ICU service due to their prematurity. The fourth newborn was not identified in any of the ultrasounds performed during pregnancy. During the postpartum period, the patient had a fulminant evolution of COVID-19 pneumonia, with rapid deterioration, needing respiratory support and antiviral treatment. Discussions: Managing high-risk obstetrical pregnancies associated with COVID-19 requires a multidisciplinary team consisting of obstetricians, anesthesiologists, neonatologists, and infectious disease doctors. Conclusion: Our case is the first to our knowledge in Romania to present an association of high-grade multiple pregancy with COVID19 moderate form, rapidly evolving postpartum, needing rapid intensive care admission, and specific treatment with Remdesivir, with good post-treatment evolution.
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Affiliation(s)
- Răzvan Socolov
- Department of Obstetrics and Gynecology, Elena Doamna Obstetrics and Gynecology University Hospital, 700398 Iasi, Romania; (R.S.); (M.P.); (D.P.); (M.C.); (R.C.); (I.P.)
- Department of Obstetrics and Gynecology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Mona Akad
- Department of Obstetrics and Gynecology, Elena Doamna Obstetrics and Gynecology University Hospital, 700398 Iasi, Romania; (R.S.); (M.P.); (D.P.); (M.C.); (R.C.); (I.P.)
- Department of Obstetrics and Gynecology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania;
- Correspondence: ; Tel.: +40-744-365-694
| | - Maricica Păvăleanu
- Department of Obstetrics and Gynecology, Elena Doamna Obstetrics and Gynecology University Hospital, 700398 Iasi, Romania; (R.S.); (M.P.); (D.P.); (M.C.); (R.C.); (I.P.)
- Department of Obstetrics and Gynecology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Diana Popovici
- Department of Obstetrics and Gynecology, Elena Doamna Obstetrics and Gynecology University Hospital, 700398 Iasi, Romania; (R.S.); (M.P.); (D.P.); (M.C.); (R.C.); (I.P.)
- Department of Obstetrics and Gynecology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Mădălina Ciuhodaru
- Department of Obstetrics and Gynecology, Elena Doamna Obstetrics and Gynecology University Hospital, 700398 Iasi, Romania; (R.S.); (M.P.); (D.P.); (M.C.); (R.C.); (I.P.)
- Department of Obstetrics and Gynecology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Roxana Covali
- Department of Obstetrics and Gynecology, Elena Doamna Obstetrics and Gynecology University Hospital, 700398 Iasi, Romania; (R.S.); (M.P.); (D.P.); (M.C.); (R.C.); (I.P.)
- Department of Obstetrics and Gynecology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Fawzy Akad
- Department of Obstetrics and Gynecology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Ioana Păvăleanu
- Department of Obstetrics and Gynecology, Elena Doamna Obstetrics and Gynecology University Hospital, 700398 Iasi, Romania; (R.S.); (M.P.); (D.P.); (M.C.); (R.C.); (I.P.)
- Department of Obstetrics and Gynecology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania;
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Seckin B, Yumusak OH, Tokmak A. Comparison of two different starting doses of recombinant follicle stimulating hormone (rFSH) for intrauterine insemination (IUI) cycles in non-obese women with polycystic ovary syndrome (PCOS): a retrospective cohort study. J OBSTET GYNAECOL 2021; 41:1234-1239. [PMID: 33624571 DOI: 10.1080/01443615.2020.1849069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
We aimed to compare the efficacy of two different starting doses of recombinant follicle stimulating hormone (rFSH), 37.5 vs. 75 international units (IU) for intrauterine insemination (IUI) cycles in non-obese women with polycystic ovary syndrome (PCOS). A total of 109 women who underwent first rFSH stimulated IUI cycle were included in this retrospective cohort study. The primary outcome measure was the clinical pregnancy rate. No significant difference was found in terms of clinical pregnancy rate between the two groups (22% for the 37.5-IU group and 24% for the 75-IU group, respectively, p = .808). There was no significant difference in monofollicular development rate among the groups (p = .354). The total rFSH consumption was lower in the 37.5-IU group compared to the 75-IU group (p< .001). There was no statistically significant difference in pregnancy rates between the 37.5-IU and 75-IU groups in both normal weight (BMI: 19-24.9 kg/m2) and overweight (BMI: 25-29.9 kg/m2) women (p = .889 and .518, respectively). These results suggest that the starting doses of 37.5 and 75 IU of rFSH do not show significant difference in clinical pregnancy rates in non-obese PCOS women undergoing IUI cycles.Impact StatementWhat is already known on this subject? Low-dose gonadotropin treatment is advised for women with polycystic ovary syndrome (PCOS). However, there are few comparative data on the efficacy of different starting doses of recombinant follicle stimulating hormone (rFSH) for intrauterine insemination (IUI) cycles in PCOS women.What the results of this study add? There was no statistically significant difference in pregnancy rates of non-obese patients with PCOS having IUI whether rFSH was started at 37.5 or 75 international units (IU).What the implications are of these findings for clinical practice and/or further research? A starting dose of 37.5 IU of rFSH may be a reasonable approach for IUI cycles in non-obese PCOS women.
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Affiliation(s)
- Berna Seckin
- Department of Reproductive Endocrinology, Zekai Tahir Burak Women's Health Education and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Omer Hamid Yumusak
- Department of Reproductive Endocrinology, Zekai Tahir Burak Women's Health Education and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Aytekin Tokmak
- Department of Reproductive Endocrinology, Zekai Tahir Burak Women's Health Education and Research Hospital, University of Health Sciences, Ankara, Turkey
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Wang R, van Eekelen R, Mochtar MH, Mol F, van Wely M. Treatment Strategies for Unexplained Infertility. Semin Reprod Med 2020; 38:48-54. [PMID: 33124018 DOI: 10.1055/s-0040-1719074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Unexplained infertility is a common diagnosis among couples with infertility. Pragmatic treatment options in these couples are directed at trying to improve chances to conceive, and consequently intrauterine insemination (IUI) with ovarian stimulation and in vitro fertilization (IVF) are standard clinical practice, while expectant management remains an important alternative. While evidence on IVF or IUI with ovarian stimulation versus expectant management was inconclusive, these interventions seem more effective in couples with a poor prognosis of natural conception. Strategies such as strict cancellation criteria and single-embryo transfer aim to reduce multiple pregnancies without compromising cumulative live birth. We propose a prognosis-based approach to manage couples with unexplained infertility so as to expose less couples to unnecessary interventions and less mothers and children to the potential adverse effects of ovarian stimulation or laboratory procedures.
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Affiliation(s)
- Rui Wang
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Rik van Eekelen
- Centre for Reproductive Medicine, Amsterdam UMC, Amsterdam, The Netherlands
| | - Monique H Mochtar
- Centre for Reproductive Medicine, Amsterdam UMC, Amsterdam, The Netherlands
| | - Femke Mol
- Centre for Reproductive Medicine, Amsterdam UMC, Amsterdam, The Netherlands
| | - Madelon van Wely
- Centre for Reproductive Medicine, Amsterdam UMC, Amsterdam, The Netherlands
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Carpinello OJ, Jahandideh S, Yamasaki M, Hill MJ, Decherney AH, Stentz N, Moon KS, Devine K. Does ovarian stimulation benefit ovulatory women undergoing therapeutic donor insemination? Fertil Steril 2020; 115:638-645. [PMID: 33077237 DOI: 10.1016/j.fertnstert.2020.08.1430] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/19/2020] [Accepted: 08/28/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To compare clinical and ongoing pregnancy after natural cycle (NC) intrauterine insemination (IUI) versus ovarian stimulation (OS) IUI in ovulatory women undergoing therapeutic donor insemination (TDI). DESIGN Retrospective cohort. SETTING Single infertility center. PATIENT(S) A total of 76,643 IUI cycles in patients treated with intrauterine insemination were examined. Women undergoing TDI in the absence of diagnosed female factor infertility were included. INTERVENTION(S) NC TDI or OS TDI with either clomiphene citrate or letrozole. MAIN OUTCOME MEASURE(S) Clinical and ongoing pregnancies were analyzed by generalized estimating equations adjusting for age, body mass index, total motile sperm at time of insemination and cycle number. Ongoing multiple gestations were examined as a secondary outcome. RESULT(S) Six thousand one hundred ninety-two TDI cycles from 2,343 patients (711 patients without repeated IUI cycles) met inclusion criteria and were available for analysis (3,837 NC and 2,355 OS). There was no difference in mean age between the two groups (NC, 34.2 years vs. OS, 34.3 years). Probability of clinical and ongoing pregnancy was higher in the OS cohort compared with the NC cohort (OS, 22.4% vs. NC, 18.7% and OS, 15.4% vs. NC, 14.9%, respectively). However, OS significantly increased ongoing multiple gestations (OS, 10.8% vs. NC, 2.4%). CONCLUSION(S) Ovarian stimulation in TDI cycles resulted in a <4% increase in clinical and <1% increase in ongoing pregnancy, and more than fourfold increase in ongoing multiple gestations. Natural cycle IUI should be considered as a first-line treatment for ovulatory women who need donor insemination.
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Affiliation(s)
- Olivia J Carpinello
- Program in Reproductive Endocrinology and Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland.
| | | | - Meghan Yamasaki
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Micah J Hill
- Program in Reproductive Endocrinology and Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland; Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Alan H Decherney
- Program in Reproductive Endocrinology and Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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9
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Use of exogenous gonadotropins for ovulation induction in anovulatory women: a committee opinion. Fertil Steril 2020; 113:66-70. [PMID: 32033726 DOI: 10.1016/j.fertnstert.2019.09.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 09/16/2019] [Indexed: 12/11/2022]
Abstract
This document reviews gonadotropin treatment for ovulation induction in anovulatory women and outlines the recommended pretreatment evaluation, indications, treatment regimens, and complications of gonadotropin treatment. It replaces the document with a similar name, last published in 2008 (Fertil Steril 2008;90:S7-12).
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Clomiphene Stair-Step Protocol for Women With Polycystic Ovary Syndrome. Obstet Gynecol 2018; 131:1165. [PMID: 29794664 DOI: 10.1097/aog.0000000000002669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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11
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Peeraer K, Luyten J, Tomassetti C, Verschueren S, Spiessens C, Tanghe A, Meuleman C, Debrock S, Dancet E, D'Hooghe T. Cost-effectiveness of ovarian stimulation with gonadotrophin and clomiphene citrate in an intrauterine insemination programme for subfertile couples. Reprod Biomed Online 2018; 36:302-310. [DOI: 10.1016/j.rbmo.2017.12.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 11/29/2017] [Accepted: 12/08/2017] [Indexed: 11/17/2022]
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Bouet PE, Legendre G, Delbos L, Dreux C, Jeanneteau P, Ferré-L'Hotellier V, Boucret L, Descamps P, May-Panloup P. [In vitro fertilization versus conversion to intrauterine insemination in patients with poor response to controlled ovarian hyperstimulation]. ACTA ACUST UNITED AC 2018; 46:118-123. [PMID: 29373313 DOI: 10.1016/j.gofs.2017.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Indexed: 11/16/2022]
Abstract
In women undergoing controlled ovarian hyperstimulation (COH) for in vitro fertilization (IVF), a poor ovarian response, defined as three of fewer mature follicles, can lead to cancellation of the cycle. However, in women with at least one patent tube and normal semen parameters, conversion to intrauterine insemination (IUI) is considered an option, offering reasonable pregnancy rates at a lower cost and without the complications associated with oocyte retrieval. Studies have shown that in cycles with only one mature follicle, IVF should be canceled. However, in cycles with 2 or 3 mature follicles, patients have the choice between IVF and conversion to IUI. Some studies have shown that IVF is superior to IUI in such cases, whereas other reports failed to find any difference. Most of these studies are retrospective and limited by the presence of several biases and low numbers of cycles, and to this date, there is no consensus on the best approach. We have thus designed a multicenter, randomized non-inferiority study, comparing live birth rates following conversion to IUI or IVF in patients with 2 or 3 mature follicles in COH cycles. Nine hundred and forty patients will be randomized on trigger day to either IVF or conversion to IUI. Our study will also include a medico-economic analysis.
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Affiliation(s)
- P-E Bouet
- Service de médecine de la reproduction, CHU d'Angers, 4, rue Larrey, 49000 Angers, France.
| | - G Legendre
- Service de médecine de la reproduction, CHU d'Angers, 4, rue Larrey, 49000 Angers, France
| | - L Delbos
- Service de médecine de la reproduction, CHU d'Angers, 4, rue Larrey, 49000 Angers, France
| | - C Dreux
- Service de médecine de la reproduction, CHU d'Angers, 4, rue Larrey, 49000 Angers, France
| | - P Jeanneteau
- Service de médecine de la reproduction, CHU d'Angers, 4, rue Larrey, 49000 Angers, France
| | - V Ferré-L'Hotellier
- Service de médecine de la reproduction, CHU d'Angers, 4, rue Larrey, 49000 Angers, France
| | - L Boucret
- Service de médecine de la reproduction, CHU d'Angers, 4, rue Larrey, 49000 Angers, France
| | - P Descamps
- Service de médecine de la reproduction, CHU d'Angers, 4, rue Larrey, 49000 Angers, France
| | - P May-Panloup
- Service de médecine de la reproduction, CHU d'Angers, 4, rue Larrey, 49000 Angers, France
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Comparative effectiveness of 9 ovulation-induction therapies in patients with clomiphene citrate-resistant polycystic ovary syndrome: a network meta-analysis. Sci Rep 2017. [PMID: 28630466 PMCID: PMC5476620 DOI: 10.1038/s41598-017-03803-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
The comparative efficacies of ovulation-induction treatments in patients with clomiphene citrate-resistant (CCR) polycystic ovary syndrome (PCOS) are not well known. Therefore, we conducted a network meta-analysis to rank the reproductive efficacies of these treatments. We ultimately included 26 randomized clinical trials with 2722 participants and 9 types of therapies: clomiphene citrate (CC), metformin, letrozole, follicle stimulating hormone (FSH), human menopausal gonadotropin (hMG), unilateral laparoscopic ovarian drilling (ULOD), bilateral laparoscopic ovarian drilling (BLOD), the combination of metformin with letrozole (metformin+letrozole), and the combination of metformin with CC (metformin+CC). The network meta-analysis demonstrates that hMG therapy result in higher pregnancy rates than BLOD, ULOD and CC therapies. Pregnancy, live birth and ovulation rates are significantly higher in metformin+letrozole and FSH groups than CC group. The abortion rate in the metformin+letrozole group is significantly lower than that in the metformin+CC group. Ranking probabilities show that, apart from gonadotropin (FSH and hMG), metformin+letrozole is also potentially more effective in improving reproductive outcomes than other therapies. In conclusion, owing to the low quality of evidence and the wide confidence intervals, no recommendation could be made for the treatment of ovulation-induction in patients with CCR PCOS.
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Ruhlmann C, Molina L, Tessari G, Ruhlmann F, Tessari L, Gnocchi D, Cattaneo A, Irigoyen M, Martínez AG. Optimizing the number of embryos to transfer on day 5: two should be the limit. JBRA Assist Reprod 2017; 21:7-10. [PMID: 28333024 PMCID: PMC5365192 DOI: 10.5935/1518-0557.20170003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective To define the appropriate number of embryos to be transferred at day 5. Methods Retrospective analysis of 784 consecutive fresh day-5 embryo transfers
performed between 2007 and 2015, divided in three groups: Group A (N = 219):
received the only 2 embryos that reached a transferable stage; Group B (N =
357): received 2 selected embryos among several that reached a transferable
stage; Group C (N = 208): received the only 3 developing embryos. Clinical
pregnancy, implantation, multiple pregnancy and delivery rates were
registered. Kruskal-Wallis and Fisher Exact tests were applied as
appropriate. Results Age and previous attempts were comparable in the 3 groups. Compared with
Group A, Groups B and C had a higher oocyte recovery (10.7 ± 5.6
vs. 14.7 ± 8.0 vs. 13.8
± 6.6), fertilization rate (75.97% vs. 81.60%
vs. 83.29%) and percentage of embryos reaching a
transferable stage on day 5 (39.98% vs. 63.99%
vs. 60.97%), as well as a significantly higher clinical
pregnancy (42.92% vs. 61.06% vs. 58.17%)
and implantation rates (21.09% vs. 40.98%
vs. 36.97%). The multiple pregnancy rate was higher in
Groups B and C than in Group A (11.70% vs. 31.19%
vs. 37.19%). The high order multiple pregnancy rate
(> 2) was significantly increased in group C (1.06% vs.
0.92% vs. 14.05%). Conclusions In patients with 3 or more day 5 developing embryos, delivery rates are
similar if 2 or 3 embryos are transferred. The transfer of 3 embryos carries
an unacceptable increase in the risk of high order multiple pregnancy, with
its known consequences. According to our data, we should not exceed the
number of 2 day-5 fresh embryos transferred.
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Peeraer K, Debrock S, De Loecker P, Tomassetti C, Laenen A, Welkenhuysen M, Meeuwis L, Pelckmans S, Mol BW, Spiessens C, De Neubourg D, D'Hooghe TM. Low-dose human menopausal gonadotrophin versus clomiphene citrate in subfertile couples treated with intrauterine insemination: a randomized controlled trial. Hum Reprod 2015; 30:1079-88. [DOI: 10.1093/humrep/dev062] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 02/20/2015] [Indexed: 11/12/2022] Open
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16
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Female obesity and infertility. Best Pract Res Clin Obstet Gynaecol 2014; 29:498-506. [PMID: 25619586 DOI: 10.1016/j.bpobgyn.2014.10.014] [Citation(s) in RCA: 160] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 10/30/2014] [Indexed: 01/11/2023]
Abstract
Infertility affects one in seven couples, and its rate is on the increase. Ovulatory defects and unexplained causes account for >50% of infertile aetiologies. It is postulated that a significant proportion of these cases are either directly or indirectly related to obesity. The prevalence of overweight and obese men and women has topped 50% in some developed countries. Obesity is on the increase worldwide; in turn, the consequences in terms of the associated morbidity and mortality have also been increasing. Obesity is associated with various reproductive sequelae including anovulation, subfertility and infertility, increased risk of miscarriage and poor neonatal and maternal pregnancy outcomes. Thus, the combination of infertility and obesity poses some very real challenges in terms of both the short- and long-term management of these patients. The mechanism with which obesity impacts female reproductive function is summarised in this review.
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Goldman RH, Batsis M, Hacker MR, Souter I, Petrozza JC. Outcomes after intrauterine insemination are independent of provider type. Am J Obstet Gynecol 2014; 211:492.e1-9. [PMID: 24881820 DOI: 10.1016/j.ajog.2014.05.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 04/23/2014] [Accepted: 05/24/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We sought to determine whether the success of intrauterine insemination (IUI) varies based on the type of health care provider performing the procedure. STUDY DESIGN This was a retrospective cohort study set at an infertility clinic at an academic institution. The patients who comprised this study were 1575 women who underwent 3475 IUI cycles from late 2003 through early 2012. Cycles were stratified into 3 groups according to the type of provider who performed the procedure: attending physician, fellow physician, or registered nurse (RN). The primary outcome was live birth. Additional outcomes of interest included positive pregnancy test and clinical pregnancy. Repeated measures log binomial regression was used to estimate the risk ratios (RR) and 95% confidence intervals (CI) for the outcomes and to evaluate the effect of potential confounders. All tests were 2-sided, and P values < .05 were considered statistically significant. RESULTS Of the 3475 IUI cycles, 2030 (58.4%) were gonadotropin stimulated, 929 (26.7%) were clomiphene citrate stimulated, and 516 (14.9%) were natural. The incidences of clinical pregnancy and live birth among all cycles were 11.8% and 8.8%, respectively. After adjusting for female age, male partner age, and cycle type, the incidence of live birth was similar for RNs compared with attending physicians (RR, 0.80; 95% CI, 0.58-1.1) and fellow physicians compared with attending physicians (RR, 0.84; 95% CI, 0.58-1.2). Similar results were seen for positive pregnancy test and clinical pregnancy. CONCLUSION There was no significant difference in live birth following IUI cycles in which the procedure was performed by a fellow physician or RN compared with an attending physician.
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Affiliation(s)
- Randi H Goldman
- Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital/Harvard Medical School, Boston, MA.
| | - Maria Batsis
- Massachusetts General Hospital Fertility Center, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Michele R Hacker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, and Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA
| | - Irene Souter
- Massachusetts General Hospital Fertility Center, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital/Harvard Medical School, Boston, MA; Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - John C Petrozza
- Massachusetts General Hospital Fertility Center, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital/Harvard Medical School, Boston, MA; Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital/Harvard Medical School, Boston, MA
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Kulkarni AD, Jamieson DJ, Jones HW, Kissin DM, Gallo MF, Macaluso M, Adashi EY. Fertility treatments and multiple births in the United States. N Engl J Med 2013; 369:2218-25. [PMID: 24304051 DOI: 10.1056/nejmoa1301467] [Citation(s) in RCA: 175] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The advent of fertility treatments has led to an increase in the rate of multiple births in the United States. However, the trends in and magnitude of the contribution of fertility treatments to the increase are uncertain. METHODS We derived the rates of multiple births after natural conception from data on distributions of all births from 1962 through 1966 (before fertility treatments were available). Publicly available data on births from 1971 through 2011 were used to determine national multiple birth rates, and data on in vitro fertilization (IVF) from 1997 through 2011 were used to estimate the annual proportion of multiple births that were attributable to IVF and to non-IVF fertility treatments, after adjustment for maternal age. Trends in multiple births were examined starting from 1998, the year when clinical practice guidelines for IVF were developed with an aim toward reducing the incidence of multiple births. RESULTS We estimated that by 2011, a total of 36% of twin births and 77% of triplet and higher-order births resulted from conception assisted by fertility treatments. The observed incidence of twin births increased by a factor of 1.9 from 1971 to 2009. The incidence of triplet and higher-order births increased by a factor of 6.7 from 1971 to 1998 and decreased by 29% from 1998 to 2011. This decrease coincided with a 70% reduction in the transfer of three or more embryos during IVF (P<0.001) and a 33% decrease in the proportion of triplet and higher-order births attributable to IVF (P<0.001). CONCLUSIONS Over the past four decades, the increased use of fertility treatments in the United States has been associated with a substantial rise in the rate of multiple births. The rate of triplet and higher-order births has declined over the past decade in the context of a reduction in the transfer of three or more embryos during IVF. (Funded by the Centers for Disease Control and Prevention.).
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Affiliation(s)
- Aniket D Kulkarni
- From the Women's Health and Fertility Branch, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta (A.D.K., D.J.J., D.M.K., M.F.G.); the Johns Hopkins School of Medicine, Baltimore (H.W.J.); the Eastern Virginia Medical School, Norfolk (H.W.J.); the Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati (M.M.); and the Warren Alpert Medical School, Brown University, Providence, RI (E.Y.A.)
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Effect of maternal height and weight on risk for preterm singleton and twin births resulting from IVF in the United States, 2008-2010. Am J Obstet Gynecol 2013; 209:349.e1-6. [PMID: 23727520 DOI: 10.1016/j.ajog.2013.05.052] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 05/08/2013] [Accepted: 05/29/2013] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To analyze the effects of preconception maternal height and weight on the risk of preterm singleton and twin births resulting from in vitro fertilization (IVF). STUDY DESIGN We performed a retrospective cohort analysis of the incidence of very early preterm birth (VEPTB), early preterm birth (EPTB), and preterm birth (PTB), before 28, 32, and 37 completed weeks, respectively, in 60,232 singleton and 24,111 twin live births using 2008-2010 live birth outcome data from the Society for Reproductive Technology Clinic Outcome Reporting System. RESULT Maternal obesity is associated with significantly increased risk of VEPTB, EPTB, and PTB in pregnancies conceived by IVF. For morbidly obese women (body mass index ≥35) with singletons, rates of VEPTB, EPTB, and PTB were 1.7%, 3.6%, and 16.4%, with adjusted risk ratios (aRRs) and 95% confidence levels (CIs) of 2.6 (1.8-3.6), 2.2 (1.8-2.6), and 1.5 (1.4-1.7) using corresponding rates for normal body mass index (95% CI, 18.6-24.9) as referent. For morbidly obese women with twins, rate of VEPTB and EPTB were 6.5% and 12.5%, with aRRs and 95% CIs of 2.4 (1.8-3.0) and 1.5 (1.3-1.8). For singletons, the rate of PTB for short stature women (<150 cm) was 14.2%, as compared with 11.8% in those women with height ranging between 160-167 cm (referent), with aRRs and 95% CIs of 1.2 (1.0-1.4). CONCLUSION Preconception maternal obesity and short stature are associated with significantly increased risk of VEPTB and early preterm singleton and twin births in pregnancies resulting from IVF.
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da Silva CH, Hernandez AR, Agranonik M, Goldani MZ. Maternal age and low birth weight: a reinterpretation of their association under a demographic transition in southern Brazil. Matern Child Health J 2013; 17:539-44. [PMID: 22535218 DOI: 10.1007/s10995-012-1030-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To evaluate the relationship between changes in fecundity rates and maternal age and the impact of maternal age on low birth weight (LBW) rates in a developed region in southern Brazil. A time series study evaluating birth weight and maternal ages through the born alive information system (SINASC) in Porto Alegre from 1996 to 2008. The Chi-square test for trends was used to evaluate the trend of LBW and fecundity rates at each maternal age. Population attributed risk (PAR) was used to calculate the impact of maternal age on LBW rates. The study included 271,100 newborns. There was a significant reduction in fecundity rates in all age groups younger than 34 years, but especially in the groups between 20 and 29 years. Overall LBW increased from 9.3 to 10.7 % (P < 0.001). The PAR for LBW showed a reduction in the group from 17 to 19 years (from 1.7 % in 1996-1999 to 0.1 % in 2004-2008), and an increase in the groups from 35 to 39 years (from 2.0 % in 1996-1999 to 2.3 % in 2004-2008) and above 40 (from 1.1 % in 1996-1999 to 1.5 % in 2004-2008). There was a significant change in fecundity pattern in the last 12 years in southern Brazil. Adolescent mothers were surpassed by mothers over 30 years of age in terms of vulnerability for LBW babies. The results show a change in the maternal age distribution towards older mothers, accompanied by an increasing incidence of LBW. This demographic transition also involved a paradoxical pattern with a remarkable reduction in fecundity rates in intermediate maternal age groups with concomitant increase in their risk for LBW.
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Affiliation(s)
- C Homrich da Silva
- Núcleo de Estudos de Saúde da Saúde da Criança e do Adolescente (NESCA), Universidade Federal do Rio Grande do Sul (UFRGS), Rua Ramiro Barcelos 2350, 10° andar (Serviço de Pediatria), Porto Alegre, Rio Grande do Sul 90035-903, Brazil.
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McDowell S, Kroon B, Yazdani A. Clomiphene ovulation induction and higher-order multiple pregnancy. Aust N Z J Obstet Gynaecol 2013; 53:395-8. [PMID: 23829327 DOI: 10.1111/ajo.12106] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 05/10/2013] [Indexed: 12/29/2022]
Abstract
Clomiphene citrate is a widely used treatment for ovulatory dysfunction in women seeking pregnancy. The major adverse consequence of clomiphene use is the increased risk of multiple and higher-order multiple pregnancy. Mechanisms for multiple pregnancy include dosing variation, adjuvant therapies, pretreatment weight loss and a cumulative effect of multiple clomiphene cycles. It has been suggested that the risk of higher-order multiple pregnancy may be reduced with ultrasound monitoring, although there is limited evidence to support this practice.
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Affiliation(s)
- Simon McDowell
- Queensland Fertility Group Research Foundation, University of Queensland, Brisbane, Queensland, Australia.
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22
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Abstract
Anovulatory disorders are a primary cause of female infertility. Polycystic ovarian syndrome is the major cause of anovulation and is generally associated with obesity. Lifestyle changes to encourage weight loss are the initial therapy for overweight and obese patients, followed by clomiphene citrate for ovulation induction. For those patients who fail to ovulate on clomiphene citrate, alternatives, such as letrozole; gonadotropins; and complimentary agents to enhance clomiphene citrate, such as metformin and glucocorticoids, are reviewed. Women with unexplained infertility (no identifiable cause of infertility on a routine evaluation) may benefit from ovulation induction with clomiphene citrate, letrozole, or gonadotropins.
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Affiliation(s)
- Anthony M Propst
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
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Balayla J, Granger L, St-Michel P, Villeneuve M, Fontaine JY, Desrosiers P, Dahdouh EM. Rescue in vitro fertilization using a GnRH antagonist in hyper-responders from gonadotropin intrauterine insemination (IUI) cycles. J Assist Reprod Genet 2013; 30:773-8. [PMID: 23715874 DOI: 10.1007/s10815-013-0016-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Accepted: 05/17/2013] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE To evaluate the outcomes in the conversion of high-response gonadotropin intrauterine insemination (IUI) cycles to "rescue" in vitro fertilization (IVF) using a Gonadotropin-Releasing Hormone (GnRH) antagonist, with regards to implantation rates, pregnancy rates, cost, and ovarian hyperstimulation syndrome (OHSS) as compared to matched, hyper-responder, IVF controls. METHODS This prospective cohort study was conducted between January 2007 and December 2009 at our institution. In order to decrease high-order multiple pregnancy, minimize the incidence of OHSS, and avoid cycle cancellation, high-response stimulated-IUI patients opted to convert to "rescue" IVF using the GnRH antagonist cetrorelix acetate. We then compared their clinical outcomes with matched patients from high-response IVF cycles of the standard long mid-luteal GnRH agonist protocol (14 or more collected oocytes). Only cases of conventional IVF without intra-cytoplasmic sperm injection (ICSI) were included in the control group. RESULTS Out of 184 patients undergoing stimulated-IUI cycles with gonadotropins, 87 patients developed a hyper-response, and 20 opted to convert to "rescue" IVF. These patients were compared with 157 matched, hyper responder IVF controls from our registry. The implantation rate was 25.6 % in the "rescue" IVF group and 20.7 % in the control IVF group (p < 0.0047). The ongoing clinical pregnancy rate per embryo transfer was 45.0 % and 33.6 % in the "rescue" IVF and the control IVF groups, respectively (p < 0.0001). The mean duration of stimulation was comparable between cohorts (10.0 vs.10.4 days, p = 0.6324). The mean dose of gonadotropin used per cycle was higher in the control group, 2664 international units (IU) of follicle stimulation hormone (FSH) compared to 1450 IU of FSH in the "rescue" IVF group (p < 0.0001). The incidence of severe OHSS is also higher in the control group, 5.1 % versus no cases in the "rescue" IVF group (p < 0.0001). CONCLUSION Our study demonstrates that conversion of high-response gonadotropin-IUI cycles to "rescue" IVF using a GnRH antagonist is a cost-effective strategy that produces better results than regular IVF with relatively minimal morbidity, and shorter duration to achieve pregnancy. Implantation and ongoing clinical pregnancy rates tend to be higher than those from hyper-responder regular IVF patients.
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Affiliation(s)
- Jacques Balayla
- Department of Obstetrics and Gynecology, University of Montreal, Montreal, Canada
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24
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Bergeron ME, Fatum M, Bujold E. Quintuplets: a rare event following clomiphene citrate therapy. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2012; 34:616. [PMID: 22742478 DOI: 10.1016/s1701-2163(16)35309-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Marie-Eve Bergeron
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Oxford, United Kingdom, Département d'obstétrique-gynécologie, Centre hospitalier universitaire de Québec, Faculté de Médecine, Université Laval, Québec
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Bhagavath B, Carson SA. Ovulation induction in women with polycystic ovary syndrome: an update. Am J Obstet Gynecol 2012; 206:195-8. [PMID: 21831351 DOI: 10.1016/j.ajog.2011.06.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Revised: 05/29/2011] [Accepted: 06/02/2011] [Indexed: 11/15/2022]
Abstract
Infertility is frequently caused by anovulation. The affected women present with irregular menstrual cycles and the most common diagnosis is polycystic ovary syndrome. Ovulation induction is commonly used to treat these women. Clomiphene citrate (a selective estrogen receptor modulator or SERM) remains the most used medication for treating this condition. Alternatives that have been used include other SERMs such as tamoxifen, aromatase inhibitors, insulin sensitizing agents, and ovarian drilling. Evidence for and against the effectiveness of these agents has fluctuated over the last decade. Controversies surrounding the use of ovulation induction such as development of functional cysts, high-order multiple births, and development of ovarian cancer have been further studied and some controversies have almost been laid to rest in the last decade.
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Affiliation(s)
- Balasubramanian Bhagavath
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Warren Alpert Medical School of Brown University, Women and Infants Hospital of Rhode Island, Providence, RI, USA
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Fong SA, Palta V, Oh C, Cho MM, Loughlin JS, McGovern PG. Multiple pregnancy after gonadotropin-intrauterine insemination: an unavoidable event? ISRN OBSTETRICS AND GYNECOLOGY 2011; 2011:465483. [PMID: 22254142 PMCID: PMC3255317 DOI: 10.5402/2011/465483] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/15/2011] [Accepted: 11/20/2011] [Indexed: 11/23/2022]
Abstract
Objective. Determine which factors predict multiple pregnancy in gonadotropin-intrauterine insemination cycles so that cancellation criteria might be developed. Study Design. Retrospective chart review of all patients undergoing gonadotropin-intrauterine insemination over a continuous 36 month period. Results. No factors examined were able to predict the occurrence of multiple pregnancy. Conclusion. Multiple pregnancy is an unavoidable complication of gonadotropin-intrauterine insemination treatment.
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Affiliation(s)
- Shirley A. Fong
- Department of Obstetrics, Gynecology, and Women's Health, New Jersey Medical School, 185 South Orange Avenue, MSB E506, Newark, NJ 07103, USA
| | - Vidya Palta
- Department of Obstetrics, Gynecology, and Women's Health, New Jersey Medical School, 185 South Orange Avenue, MSB E506, Newark, NJ 07103, USA
| | - Cheongeun Oh
- Division of Biostatistics, New York University School of Medicine, 650 First Avenue Room 556/558, New York, NY 10016, USA
| | - Michael M. Cho
- Department of Obstetrics, Gynecology, and Women's Health, New Jersey Medical School, 185 South Orange Avenue, MSB E506, Newark, NJ 07103, USA
| | - Jacquelyn S. Loughlin
- Department of Obstetrics, Gynecology, and Women's Health, New Jersey Medical School, 185 South Orange Avenue, MSB E506, Newark, NJ 07103, USA
| | - Peter G. McGovern
- Department of Obstetrics, Gynecology, and Women's Health, New Jersey Medical School, 185 South Orange Avenue, MSB E506, Newark, NJ 07103, USA
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Bruna-Catalán I, Menabrito M. Ovulation induction with minimal dose of follitropin alfa: a case series study. Reprod Biol Endocrinol 2011; 9:142. [PMID: 22024419 PMCID: PMC3214140 DOI: 10.1186/1477-7827-9-142] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Accepted: 10/24/2011] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Gonadotropins are used in ovulation induction (OI) for patients with anovulatory infertility. Pharmacologic OI is associated with risks of ovarian hyperstimulation syndrome and multiple pregnancy. Treatment protocols that minimize these risks by promoting monofollicular development are required. A starting dose of 37.5 IU/day follitropin alfa has been used in OI, particularly among women at high risk of multifollicular development and multiple pregnancy. A retrospective case series study was performed to evaluate rates of monofollicular development and singleton pregnancy following standard treatment with 37.5 IU/day follitropin alfa. METHODS Spanish centers that had performed at least five OI cycles during 2008 using 37.5 IU/day follitropin alfa as a starting dose were invited to participate. Data could be provided from any cycle performed in 2008 (up to a maximum of 12 consecutive cycles per site). Case report forms were collected during April-November 2009 and reviewed centrally. Descriptive statistics were obtained from all cases, and follicular development and clinical pregnancy rates assessed. Potential associations of age and body mass index with follicular development and clinical pregnancy were assessed using univariate correlation analyses. RESULTS Thirty centers provided data on 316 cycles of OI using a starting dose of 37.5 IU/day follitropin alfa. Polycystic ovary syndrome was the cause of anovulatory infertility in 217 (68.7%) cases. Follitropin alfa at 37.5 IU/day was sufficient to achieve ovarian stimulation in 230 (72.8%) cycles. A single follicle≥16 mm in diameter developed in 193 cycles (61.1%; 95% confidence interval [CI] 55.7-66.4%). Seventy-eight women (24.7%; 95% CI 19.9-29.5%) became pregnant: 94.9% singleton and 5.1% twin pregnancies. Fourteen started cycles (4.4%) were cancelled, mainly due to poor response. Univariate correlation analyses detected weak associations. CONCLUSIONS Monofollicular growth rate was comparable with optimal rates reported elsewhere and the pregnancy rate exceeded that in other studies of OI using gonadotropins. A starting dose of 37.5 IU/day follitropin alfa is an effective option in selected cases to prevent ovarian hyper-response without loss of efficacy. The analysis could not identify a single selection criterion for individuals who would benefit from this treatment approach; this merits further investigation in prospective studies.
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Affiliation(s)
| | - Marco Menabrito
- Medical Department, Merck, S.L., an affiliate of Merck KGaA Darmstadt Germany, Madrid, Spain
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Sarhan A, Beydoun H, Jones HW, Bocca S, Oehninger S, Stadtmauer L. Gonadotrophin ovulation induction and enhancement outcomes: analysis of more than 1400 cycles. Reprod Biomed Online 2011; 23:220-6. [PMID: 21665547 DOI: 10.1016/j.rbmo.2011.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Revised: 05/09/2011] [Accepted: 05/09/2011] [Indexed: 10/18/2022]
Abstract
Ovulation induction (OI) or ovulation enhancement (OE) with gonadotrophins can be a reasonable treatment option for patients with a variety of infertility diagnoses. It must be used with extensive monitoring and management given the risk of multiple pregnancy,especially high-order multiples. This retrospective study evaluated per cycle outcomes of a large cohort of 1452 gonadotrophin OI/OE cycles at an academic infertility centre, and the efficacy of specific guidelines in limiting multiple pregnancy. The lowest possible gonadotrophin doses were used and cycle cancellation was recommended if more than three dominant follicles were present, and/or ifserum oestradiol was above 1500 pg/ml. Overall, pregnancy rate (PR) was 12% and live birth rate was 7.7%, with an increasing trend in younger patients (P = 0.0002 and <0.0001, respectively). Multiple clinical PR was 2.6% with 1.9% twins and 0.7% triplets and above.The birthweight of a singleton from a vanishing twin pregnancy (n = 8)was significantly lower than other singletons (2882 g versus 3250 g,P = 0.013). Reducing multiple pregnancies from OI/OE cycles remains an important and challenging goal. In this large cohort, high-order multiple clinical PR was limited to 0.7% per cycle by using specific management strategies while maintaining a reasonable PR.
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Affiliation(s)
- Abbaa Sarhan
- The Jones Institute for Reproductive Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, 601 Colley Avenue, Norfolk, VA 23507, USA.
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Wallwiener LM, Rösner S, Goeckenjan M, Strowitzki T, Toth B. Therapieoptionen bei polyzystischem Ovarsyndrom mit oder ohne Kinderwunsch. GYNAKOLOGISCHE ENDOKRINOLOGIE 2011. [DOI: 10.1007/s10304-010-0399-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Assisted Reproductive Technology-Related Multiple Births: Canada in an International Context. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2011; 33:159-167. [DOI: 10.1016/s1701-2163(16)34803-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Katz P, Showstack J, Smith JF, Nachtigall RD, Millstein SG, Wing H, Eisenberg ML, Pasch LA, Croughan MS, Adler N. Costs of infertility treatment: results from an 18-month prospective cohort study. Fertil Steril 2010; 95:915-21. [PMID: 21130988 DOI: 10.1016/j.fertnstert.2010.11.026] [Citation(s) in RCA: 131] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Revised: 09/24/2010] [Accepted: 11/09/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To examine resource use (costs) by women presenting for infertility evaluation and treatment over 18 months, regardless of treatment pursued. DESIGN Prospective cohort study in which women were followed for 18 months. SETTING Eight infertility practices. PATIENT(S) Three hundred ninety-eight women recruited from infertility practices. INTERVENTION(S) Women completed interviews and questionnaires at baseline and after 4, 10, and 18 months of follow-up. Medical records were abstracted after 18 months to obtain details of services used. MAIN OUTCOME MEASURE(S) Per-person and per-successful-outcome costs. RESULT(S) Treatment groups were defined as highest intensity treatment use. Twenty percent of women did not pursue cycle-based treatment; approximately half pursued IVF. Median per-person costs ranged from $1,182 for medications only to $24,373 and $38,015 for IVF and IVF-donor egg groups, respectively. Estimates of costs of successful outcomes (delivery or ongoing pregnancy by 18 months) were higher--$61,377 for IVF, for example--reflecting treatment success rates. Within the time frame of the study, costs were not significantly different for women whose outcomes were successful and women whose outcomes were not. CONCLUSION(S) Although individual patient costs vary, these cost estimates developed from actual patient treatment experiences may provide patients with realistic estimates to consider when initiating infertility treatment.
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Affiliation(s)
- Patricia Katz
- Department of Medicine, University of California, San Francisco, California 94143-0920, USA.
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Abstract
To elaborate guidelines for the use of different treatment and different protocols for ovarian stimulation. SEARCHED STRATEGY: We searched for all publications which described randomised controlled trial evaluating different ovarian stimulation protocols and different indications on PubMed, Medline and Cochrane Database. The keywords were: ovulation induction, citrate of clomiphene, gonadotropin, metformin, anti estrogens, anti aromatase, pulsatile GnRH administration, cancer, ovarian hyperstimulation, thrombosis, multiple pregnancies, and complications. Randomised controlled trials were first considered. Then was considered recent meta analysis and cohort study. We mentioned when literature was weak.
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Affiliation(s)
- L Jacquesson
- Centre de médecine de la reproduction, 17 rue de la Pompe, 75116 Paris, France.
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Li HWR, Van Esch M, De Vries J, Duncan WC, Anderson RA. Gonadotrophin ovulation induction is a successful treatment for World Health Organisation Group II anovulatory subfertility in women aged up to 40 and with body mass index up to 34. HUM FERTIL 2010; 13:35-40. [PMID: 20141336 DOI: 10.3109/14647270903490765] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Gonadotrophin-induced ovulation (GnOI) is generally an effective treatment when anti-estrogen therapy is unsuccessful. It remains uncertain how appropriate it is in older and obese women. We carried out an analysis of a GnOI programme between 2000 and 2008, including 514 treatment cycles in 140 women with World Health Organisation Group II anovulation. A low-dose step-up stimulation protocol using recombinant follicle stimulating hormone (FSH) (with natural intercourse) was used throughout in the treatment of women aged up to 40 years and with body mass index (BMI) up to 34 kg/m(2), with a rigorously-applied cancellation criterion. The livebirth rates in first stimulated cycle and cumulatively over six cycles (or until pregnancy) were 19.2% and 74.2%, respectively and the multiple livebirth rate was 2.5%. There was no significant relationship between age and BMI with pregnancy rates, although higher BMI was associated with higher threshold dose and longer duration of stimulation. Anti-estrogen resistant patients attained significantly higher cumulative ongoing pregnancy rates than those who were anti-estrogen responsive. These data demonstrate that judicious administration of gonadotrophins to women with WHO Group II anovulatory subfertility can result in a good pregnancy rate with low risk of multiple pregnancy in women aged up to 40 years and with BMI of up to 34 kg/m(2).
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Affiliation(s)
- H W Raymond Li
- Edinburgh Fertility and Reproductive Endocrine Centre, Royal Infirmary of Edinburgh, Edinburgh, UK.
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Gallot V, Even M, Da Silva ALB, Grynberg M, Lamazou F, Fanchin R. [Against performing homologous intrauterine insemination beyond 35 years of age]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2010; 38:290-291. [PMID: 20374977 DOI: 10.1016/j.gyobfe.2010.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- V Gallot
- Service de gynécologie-obstétrique et médecine de la reproduction, hôpital Antoine-Béclère, AP-HP, Université Paris-Sud, Clamart, France.
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Stoop D, Van Landuyt L, Paquay R, Fatemi H, Blockeel C, De Vos M, Camus M, Van den Abbeel E, Devroey P. Offering excess oocyte aspiration and vitrification to patients undergoing stimulated artificial insemination cycles can reduce the multiple pregnancy risk and accumulate oocytes for later use. Hum Reprod 2010; 25:1213-8. [PMID: 20172866 DOI: 10.1093/humrep/deq026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The prevention of multiple pregnancies remains a major challenge in patients treated with ovarian stimulation prior to intrauterine insemination (IUI). The pilot study presented here investigates whether multiple pregnancies can be minimized by a microscopically confirmed aspiration of oocytes from supernumerary follicles immediately before intrauterine insemination and evaluates the benefit of concomitant excess oocyte cryopreservation for future use. METHODS Thirty-four aspirations of supernumerary follicles were performed immediately prior to IUI in 31 patients undergoing ovarian stimulation. sIUI was only performed if cumulus-oocyte complexes were microscopically observed in the aspirated follicular fluid. All collected mature excess oocytes were cryopreserved using the vitrification technique. RESULTS Only four sIUI procedures had to be cancelled due to failed oocyte retrieval or premature ovulation. IUI treatment resulted in a clinical pregnancy rate of 23.5% per cycle. All were singleton pregnancies. A total of 111 oocytes were cryopreserved. Patients with polycystic ovary syndrome (PCOS) had an average of 6.07 oocytes vitrified, whereas patients without PCOS had 1.3 oocytes vitrified per cycle. CONCLUSION Microscopically confirmed collection of excess oocytes prior to stimulated IUI reduced cancellation rates, further reduced the risk for multiple pregnancy and may lead to future additional pregnancies because, based on current information, approximately 5% of the vitrified oocytes could potentially establish a pregnancy.
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Affiliation(s)
- D Stoop
- Centre for Reproductive Medicine, University Hospital, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium.
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Crosignani P. Prevention of multiple pregnancy. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2010. [DOI: 10.1016/j.mefs.2010.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Ata B, Tulandi T. Reassurance of safety of letrozole and suggested approaches in controlled ovarian hyperstimulation. Fertil Steril 2009; 92:e6. [PMID: 19482276 DOI: 10.1016/j.fertnstert.2009.03.103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Revised: 03/30/2009] [Accepted: 03/30/2009] [Indexed: 10/20/2022]
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