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Van Muylder A, D'Hooghe T, Luyten J. Economic Evaluation of Medically Assisted Reproduction: A Methodological Systematic Review. Med Decis Making 2023; 43:973-991. [PMID: 37621143 DOI: 10.1177/0272989x231188129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
BACKGROUND Medically assisted reproduction (MAR) is a challenging application area for health economic evaluations, entailing a broad range of costs and outcomes, stretching out long-term and accruing to several parties. PURPOSE To systematically review which costs and outcomes are included in published economic evaluations of MAR and to compare these with health technology assessment (HTA) prescriptions about which cost and outcomes should be considered for different evaluation objectives. DATA SOURCES HTA guidelines and systematic searches of PubMed Central, Embase, WOS CC, CINAHL, Cochrane (CENTRAL), HTA, and NHS EED. STUDY SELECTION All economic evaluations of MAR published from 2010 to 2022. DATA EXTRACTION A predetermined data collection form summarized study characteristics. Essential costs and outcomes of MAR were listed based on HTA and treatment guidelines for different evaluation objectives. For each study, included costs and outcomes were reviewed. DATA SYNTHESIS The review identified 93 cost-effectiveness estimates, of which 57% were expressed as cost-per-(healthy)-live-birth, 19% as cost-per-pregnancy, and 47% adopted a clinic perspective. Few adopted societal perspectives and only 2% used quality-adjusted life-years (QALYs). Broader evaluations omitted various relevant costs and outcomes related to MAR. There are several cost and outcome categories for which available HTA guidelines do not provide conclusive directions regarding inclusion or exclusion. LIMITATIONS Studies published before 2010 and of interventions not clearly labeled as MAR were excluded. We focus on methods rather than which MAR treatments are cost-effective. CONCLUSIONS Economic evaluations of MAR typically calculate a short-term cost-per-live-birth from a clinic perspective. Broader analyses, using cost-per-QALY or BCRs from societal perspectives, considering the full scope of reproduction-related costs and outcomes, are scarce and often incomplete. We provide a summary of costs and outcomes for future research guidance and identify areas requiring HTA methodological development. HIGHLIGHTS The cost-effectiveness of MAR procedures can be exceptionally complex to estimate as there is a broad range of costs and outcomes involved, in principle stretching out over multiple generations and over many stakeholders.We list 21 key areas of costs and outcomes of MAR. Which of these needs to be accounted for alters for different evaluation objectives (determined by the type of economic evaluation, time horizon considered, and perspective).Published studies mostly investigate cost-effectiveness in the very short-term, from a clinic perspective, expressed as cost-per-live-birth. There is a lack of comprehensive economic evaluations that adopt a broader perspective with a longer time horizon. The broader the evaluation objective, the more relevant costs and outcomes were excluded.For several costs and outcomes, particularly those relevant for broader, societal evaluations of MAR, the inclusion or exclusion is theoretically ambiguous, and HTA guidelines do not offer sufficient guidance.
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Affiliation(s)
- Astrid Van Muylder
- Department Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium (AVM, JL); Research Group Reproductive Medicine, Department of Development and Regeneration, Organ Systems, Group Biomedical Sciences, KU Leuven (University of Leuven), Belgium (TD); Department of Obstetrics, Gynecology and Reproductive Sciences Yale School of Medicine, New Haven, CT, USA (TD); Global Medical Affairs Fertility, Research and Development, Merck Healthcare KGaA, Darmstadt, Germany (TD). The review was written at the Leuven Institute for Healthcare Policy. It was presented at the ESHRE 38th Annual Meeting (Milan 2022). The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Astrid Van Muylder and Jeroen Luyten have no conflicting interests to declare. The participation of Thomas D'Hooghe to this publication is part of his academic work; he does not see a conflict of interest as Merck KGaA was not involved in writing this article. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We acknowledge an internal funding from KU Leuven for this study. The funding agreement ensured the authors' independence in designing the study, interpreting the data, writing, and publishing the report. The following authors are employed by the sponsor: Astrid Van Muylder and Jeroen Luyten
| | - Thomas D'Hooghe
- Department Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium (AVM, JL); Research Group Reproductive Medicine, Department of Development and Regeneration, Organ Systems, Group Biomedical Sciences, KU Leuven (University of Leuven), Belgium (TD); Department of Obstetrics, Gynecology and Reproductive Sciences Yale School of Medicine, New Haven, CT, USA (TD); Global Medical Affairs Fertility, Research and Development, Merck Healthcare KGaA, Darmstadt, Germany (TD). The review was written at the Leuven Institute for Healthcare Policy. It was presented at the ESHRE 38th Annual Meeting (Milan 2022). The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Astrid Van Muylder and Jeroen Luyten have no conflicting interests to declare. The participation of Thomas D'Hooghe to this publication is part of his academic work; he does not see a conflict of interest as Merck KGaA was not involved in writing this article. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We acknowledge an internal funding from KU Leuven for this study. The funding agreement ensured the authors' independence in designing the study, interpreting the data, writing, and publishing the report. The following authors are employed by the sponsor: Astrid Van Muylder and Jeroen Luyten
| | - Jeroen Luyten
- Department Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium (AVM, JL); Research Group Reproductive Medicine, Department of Development and Regeneration, Organ Systems, Group Biomedical Sciences, KU Leuven (University of Leuven), Belgium (TD); Department of Obstetrics, Gynecology and Reproductive Sciences Yale School of Medicine, New Haven, CT, USA (TD); Global Medical Affairs Fertility, Research and Development, Merck Healthcare KGaA, Darmstadt, Germany (TD). The review was written at the Leuven Institute for Healthcare Policy. It was presented at the ESHRE 38th Annual Meeting (Milan 2022). The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Astrid Van Muylder and Jeroen Luyten have no conflicting interests to declare. The participation of Thomas D'Hooghe to this publication is part of his academic work; he does not see a conflict of interest as Merck KGaA was not involved in writing this article. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We acknowledge an internal funding from KU Leuven for this study. The funding agreement ensured the authors' independence in designing the study, interpreting the data, writing, and publishing the report. The following authors are employed by the sponsor: Astrid Van Muylder and Jeroen Luyten
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Wang J, Zhang J, Zhao N, Ma Y, Wang X, Gou X, Ju Y, Zhang H, Chen S, Wang X. The effect of ovarian stimulation on aneuploidy of early aborted tissues and preimplantation blastocysts: comparison of the GnRH agonist long protocol with the GnRH antagonist protocol. J Assist Reprod Genet 2022; 39:1927-1936. [PMID: 35767166 PMCID: PMC9428094 DOI: 10.1007/s10815-022-02557-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 06/21/2022] [Indexed: 01/19/2023] Open
Abstract
PURPOSE To compare aneuploidy rates in early aborted tissues or blastocysts between in vitro fertilization (IVF) cycles after the gonadotropin-releasing hormone (GnRH) antagonist (GnRH-ant) protocol or the GnRH agonist (GnRH-a) long protocol. METHODS This was a retrospective cohort study from a university-affiliated fertility center. In total, 550 early miscarriage patients who conceived through IVF/intracytoplasmic sperm injection (ICSI) after receiving the GnRH-ant or GnRH-a long protocol were analyzed to compare aneuploidy rates in early aborted tissues. To compare aneuploidy rates in blastocysts, 404 preimplantation genetic testing for aneuploidy (PGT-A) cycles with the GnRH-ant protocol or GnRH-a long protocol were also analyzed. RESULTS For early miscarriage patients who conceived through IVF/ICSI, compared to the GnRH-a long protocol group, the GnRH-ant protocol group had a significantly higher rate of aneuploidy in early aborted tissues (48.51% vs. 64.19%). Regarding PGT-A cycles, the rate of blastocyst aneuploidy was significantly higher in the GnRH-ant protocol group than the GnRH-a long protocol group (39.69% vs. 52.27%). After stratification and multiple linear regression, the GnRH-ant regimen remained significantly associated with an increased risk of aneuploidy in early aborted tissues and blastocysts [OR (95% CI) 1.81 (1.21, 2.71), OR (95% CI) 1.65 (1.13, 2.42)]. Furthermore, the blastocyst aneuploidy rate in the GnRH-ant protocol group was significantly higher but only in young and normal ovarian responders [OR (95% CI) 5.07 (1.99, 12.92)]. CONCLUSION Compared to the GnRH-a long protocol, the GnRH-ant protocol is associated with a higher aneuploidy rate in early aborted tissues and blastocysts. These results should be confirmed in a multicenter, randomized controlled trial.
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Affiliation(s)
- Jun Wang
- Center for Reproductive Medicine, Department of Gynecology & Obsterics, Tang Du Hospital, the Air Force Military Medical University, Xi’an, Shaan xi People’s Republic of China
| | - Jing Zhang
- Center for Reproductive Medicine, Department of Gynecology & Obsterics, Tang Du Hospital, the Air Force Military Medical University, Xi’an, Shaan xi People’s Republic of China
| | - Nan Zhao
- Center for Reproductive Medicine, Department of Gynecology & Obsterics, Tang Du Hospital, the Air Force Military Medical University, Xi’an, Shaan xi People’s Republic of China
| | - Yuan Ma
- Center for Reproductive Medicine, Department of Gynecology & Obsterics, Tang Du Hospital, the Air Force Military Medical University, Xi’an, Shaan xi People’s Republic of China
| | - Xiyi Wang
- Center for Reproductive Medicine, Department of Gynecology & Obsterics, Tang Du Hospital, the Air Force Military Medical University, Xi’an, Shaan xi People’s Republic of China
| | - Xingqing Gou
- Center for Reproductive Medicine, Department of Gynecology & Obsterics, Tang Du Hospital, the Air Force Military Medical University, Xi’an, Shaan xi People’s Republic of China
| | - Ying Ju
- Center for Reproductive Medicine, Department of Gynecology & Obsterics, Tang Du Hospital, the Air Force Military Medical University, Xi’an, Shaan xi People’s Republic of China
| | - Hengde Zhang
- Center for Reproductive Medicine, Department of Gynecology & Obsterics, Tang Du Hospital, the Air Force Military Medical University, Xi’an, Shaan xi People’s Republic of China
| | - Shuqiang Chen
- Center for Reproductive Medicine, Department of Gynecology & Obsterics, Tang Du Hospital, the Air Force Military Medical University, Xi’an, Shaan xi People’s Republic of China
| | - Xiaohong Wang
- Center for Reproductive Medicine, Department of Gynecology & Obsterics, Tang Du Hospital, the Air Force Military Medical University, Xi’an, Shaan xi People’s Republic of China
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JING M, ZHANG R. [Economic studies of in vitro fertilization and embryo transfer]. Zhejiang Da Xue Xue Bao Yi Xue Ban 2019; 48:580-585. [PMID: 31901035 PMCID: PMC8800743 DOI: 10.3785/j.issn.1008-9292.2019.10.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 06/25/2019] [Indexed: 06/10/2023]
Abstract
In vitro fertilization and embryo transplantation (IVF-ET) technology is one of the main treatments for infertility. But IVF-ET is expensive and has not be covered by health insurance in most developing countries. Therefore, how to obtain the maximum success rate with the minimum cost is a common concern of clinicians and patients. At present, the economic studies on IVF-ET mainly focus on different ovulation stimulating drugs, different ovulation stimulating protocols, different transplantation methods and the number of transplants. But the process of IVF-ET is complex, the relevant methods of economic study are diverse, and there are no unified standard for outcome indicators, so there is no unified conclusion for more economical and effective protocol by now. Therefore, to analyze the economic studies of IVF-ET, and to explore appropriate evaluation methods and cost-effective protocols will be helpful for reasonable allocation of medical resources and guidance of clinical selection. It would provide policy reference to include the costs of IVF-ET treatment in health insurance in the future.
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Affiliation(s)
| | - Runju ZHANG
- 张润驹(1978-), 男, 博士, 副主任医师, 硕士生导师, 主要从事生殖内分泌、子宫内膜容受性、胚胎着床研究; E-mail:
;
https://orcid.org/0000-0003-4438-4416
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Pan W, Tu H, Jin L, Hu C, Li Y, Wang R, Huang W, Liao S. Decision analysis about the cost-effectiveness of different in vitro fertilization-embryo transfer protocol under considering governments, hospitals, and patient. Medicine (Baltimore) 2019; 98:e15492. [PMID: 31083186 PMCID: PMC6531099 DOI: 10.1097/md.0000000000015492] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The aim of this study was to explore the benefits of in vitro fertilization (IVF) for patients and hospitals under different protocols and if IVF treatment should be incorporated into health care. PERSPECTIVE The government should consider including IVF treatment in health insurance. Hospitals and patients could obtain the best benefit by following the hospital's recommended protocol. SETTING This retrospective study was conducted from January 2014 to August 2017 at an academic hospital. METHODS A total of 7440 patients used gonadotropin-releasing hormone agonists (GnRHa) protocol, 2619 patients used, gonadotropin-releasing hormone antagonists (GnRHant) protocol, and 1514 patients used GnRHa ultra-long protocol. Primary outcomes were live birth rate (LBR), cost-effectiveness, hospital revenue, and government investment. RESULTS The cycle times for the GnRHa protocol and the GnRHa ultra-long protocol were significantly higher than the GnRHant protocol. Patients who were ≤29 years chose the GnRHant protocol. The cost of a successful cycle was 67,579.39 ± 9,917.55 ¥ and LBR was 29.25%. Patients who were >30 years had the GnRHa protocol as the dominant strategy, as it was more effective at lower costs and higher LBR. When patients were >30 to ≤34 years, the cost of a successful cycle was 66,556.7 ± 8,448.08 ¥ and the LBR was 31.05%. When patients were >35 years, the cost of a successful cycle was 83,297.92 ± 10,918.05 ¥ and the LBR was 25.07%. The government reimbursement for a cycle ranged between 11,372.12 ± 2,147.71 ¥ and 12,753.67 ± 1,905.02 ¥. CONCLUSIONS The government should consider including IVF treatment in health insurance. Hospitals recommend the GnRHant protocol for patients <29 years old and the GnRHa protocol for patients >30 years old, to obtain the best benefits. Patients could obtain the best benefit by using the protocol recommended by the hospital.
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Affiliation(s)
- Wei Pan
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei
- School of Economic and Management, Wuhan University, Wuhan
- Management Science and Data Analytics Research Center, Wuhan University, Wuhan, China
| | - Haiting Tu
- School of Economic and Management, Wuhan University, Wuhan
- Management Science and Data Analytics Research Center, Wuhan University, Wuhan, China
| | - Lei Jin
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei
| | - Cheng Hu
- School of Economic and Management, Wuhan University, Wuhan
- Management Science and Data Analytics Research Center, Wuhan University, Wuhan, China
| | - Yuehan Li
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei
| | - Renjie Wang
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei
| | - Weiming Huang
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei
| | - ShuJie Liao
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei
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Analysis of embryo quality with luteal phase ovarian stimulation after failed in vitro fertilization-embryo transfer with long or ultra-long protocol. J Gynecol Obstet Hum Reprod 2019; 48:527-529. [PMID: 30898634 DOI: 10.1016/j.jogoh.2019.03.011] [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: 11/28/2018] [Revised: 02/21/2019] [Accepted: 03/15/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To investigate the effect of luteal phase ovarian stimulation on embryo quality after failed in vitro fertilization-embryo transfer with long or ultra-long protocol. METHODS In patients who underwent luteal phase ovarian stimulation after failed in vitro fertilization-embryo transfer with long or ultra-long protocol in the reproductive center between January 2015 and October 2017, self-control observations and statistical analyses were carried out for the number of oocytes retrieved, the rate of fertilization, the rate of D3 high-quality embryos, the rate of transplantable blastocyst formation, and the pregnancy rate of transfer cycle between long or ultra-long protocol and luteal phase ovarian stimulation. RESULTS The rate of fertilization and blastocyst were significantly increased after luteal phase ovarian stimulation (P < 0.05). However, the difference of the number of oocytes retrieved and the rate of D3 high-quality embryos was not statistically significant (p > 0.05). CONCLUSIONS The patients who failed with long protocol or ultra-long protocol due to low quality embryos, the protocol changed over to luteal phase ovarian stimulation. Can significantly improve the rate of fertilization oocytes and the transplantable blastocyst, and improve the outcome of clinical pregnancy. It provides an alternative ovarian stimulation protocol in patients with IVF-ET failure.
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Iaconelli CAR, Setti AS, Braga DPAF, Maldonado LGL, Iaconelli A, Borges E, Aoki T. Concomitant use of FSH and low-dose recombinant hCG during the late follicular phase versus conventional controlled ovarian stimulation for intracytoplasmic sperm injection cycles. HUM FERTIL 2017; 20:285-292. [PMID: 28325095 DOI: 10.1080/14647273.2017.1303197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The objective of this study was to investigate the effects of low-dose hCG supplementation on ICSI outcomes and controlled ovarian stimulation (COS) cost. Three hundred and thirty patients undergoing ICSI were split into groups according to the COS protocol: (i) control group (n = 178), including patients undergoing conventional COS treatment; and (ii) low-dose hCG group (n = 152), including patients undergoing COS with low-dose hCG supplementation. Lower mean total doses of FSH administered and higher mean oestradiol level and mature oocyte rates were observed in the low-dose hCG group. A significantly higher fertilization rate, high-quality embryo rate and blastocyst formation rate were observed in the low-dose hCG group as compared to the control group. The miscarriage rate was significantly higher in the control group compared to the low-dose hCG group. A significantly lower incidence of OHSS was observed in the low-dose hCG group. There was also a significantly lower gonadotropin cost in the low-dose hCG group as compared to the control group ($1235.0 ± 239.0×$1763.0 ± 405.3, p < 0.001). The concomitant use of low-dose hCG and FSH results in a lower abortion rate and increased number of mature oocytes retrieved, as well as improved oocyte quality, embryo quality and blastocyst formation and reduced FSH requirements.
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Affiliation(s)
- Carla Andrade Rebello Iaconelli
- a Fertility Medical Group, clinical department ; Sao Paulo , SP , Brazil.,b Faculdade de Ciências Médicas da Santa Casa de São Paulo, health sciences department ; Sao Paulo , SP , Brazil
| | - Amanda Souza Setti
- b Faculdade de Ciências Médicas da Santa Casa de São Paulo, health sciences department ; Sao Paulo , SP , Brazil.,c Instituto Sapientiae - Centro de Estudos e Pesquisa em Reproducão Assistida , Sao Paulo , SP , Brazil.,d Fertility Medical Group , scientific department ; Sao Paulo , SP , Brazil
| | - Daniela Paes Almeida Ferreira Braga
- c Instituto Sapientiae - Centro de Estudos e Pesquisa em Reproducão Assistida , Sao Paulo , SP , Brazil.,d Fertility Medical Group , scientific department ; Sao Paulo , SP , Brazil.,e Disciplina de Urologia, Area de Reproducão Humana, Departamento de Cirurgia , Universidade Federal de São Paulo , Sao Paulo , SP , Brazil
| | | | - Assumpto Iaconelli
- a Fertility Medical Group, clinical department ; Sao Paulo , SP , Brazil.,c Instituto Sapientiae - Centro de Estudos e Pesquisa em Reproducão Assistida , Sao Paulo , SP , Brazil.,d Fertility Medical Group , scientific department ; Sao Paulo , SP , Brazil
| | - Edson Borges
- a Fertility Medical Group, clinical department ; Sao Paulo , SP , Brazil.,c Instituto Sapientiae - Centro de Estudos e Pesquisa em Reproducão Assistida , Sao Paulo , SP , Brazil.,d Fertility Medical Group , scientific department ; Sao Paulo , SP , Brazil
| | - Tsutomu Aoki
- b Faculdade de Ciências Médicas da Santa Casa de São Paulo, health sciences department ; Sao Paulo , SP , Brazil
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Ou J, Xing W, Li T, Li Y, Xu Y, Zhou C. Short versus long gonadotropin-releasing hormone analogue suppression protocols in advanced age women undergoing IVF/ICSI. Gynecol Endocrinol 2016; 32:622-624. [PMID: 26891055 DOI: 10.3109/09513590.2016.1147546] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To compare the effective of two GnRH-a protocols for ovarian stimulation in advanced age women undergoing IVF/ICSI cycles. STUDY DESIGN A total of 1149 IVF-ET/ICSI cycles were retrospectively identified. The cycles were divided two groups, namely a long-protocol group and a short-protocol group. RESULTS The numbers of oocytes retrieved, and high-quality embryos in the long-protocol group were significantly greater than those in the short-protocol group. In the long-protocol group, the implantation and pregnancy rates were 17.22% and 33.67%, respectively, and these values were significantly higher than those in the short-protocol group (8.24% and 15.96%, p < 0.05). CONCLUSIONS Our study demonstrated that the long protocol was superior to the short protocol for advanced age women.
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Affiliation(s)
- Jianping Ou
- a Center for Reproductive Medicine, The Third Affiliated Hospital of Sun Yat-Sen University , Guangzhou , China and
| | - Weijie Xing
- a Center for Reproductive Medicine, The Third Affiliated Hospital of Sun Yat-Sen University , Guangzhou , China and
| | - Tao Li
- a Center for Reproductive Medicine, The Third Affiliated Hospital of Sun Yat-Sen University , Guangzhou , China and
| | - Yubin Li
- b Center for Reproductive Medicine, The First Affiliated Hospital of Sun Yat-Sen University , Guangzhou , China
| | - Yanwen Xu
- b Center for Reproductive Medicine, The First Affiliated Hospital of Sun Yat-Sen University , Guangzhou , China
| | - Canquan Zhou
- b Center for Reproductive Medicine, The First Affiliated Hospital of Sun Yat-Sen University , Guangzhou , China
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Al‐Inany HG, Youssef MA, Ayeleke RO, Brown J, Lam WS, Broekmans FJ. Gonadotrophin-releasing hormone antagonists for assisted reproductive technology. Cochrane Database Syst Rev 2016; 4:CD001750. [PMID: 27126581 PMCID: PMC8626739 DOI: 10.1002/14651858.cd001750.pub4] [Citation(s) in RCA: 121] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Gonadotrophin-releasing hormone (GnRH) antagonists can be used to prevent a luteinizing hormone (LH) surge during controlled ovarian hyperstimulation (COH) without the hypo-oestrogenic side-effects, flare-up, or long down-regulation period associated with agonists. The antagonists directly and rapidly inhibit gonadotrophin release within several hours through competitive binding to pituitary GnRH receptors. This property allows their use at any time during the follicular phase. Several different regimens have been described including multiple-dose fixed (0.25 mg daily from day six to seven of stimulation), multiple-dose flexible (0.25 mg daily when leading follicle is 14 to 15 mm), and single-dose (single administration of 3 mg on day 7 to 8 of stimulation) protocols, with or without the addition of an oral contraceptive pill. Further, women receiving antagonists have been shown to have a lower incidence of ovarian hyperstimulation syndrome (OHSS). Assuming comparable clinical outcomes for the antagonist and agonist protocols, these benefits would justify a change from the standard long agonist protocol to antagonist regimens. This is an update of a Cochrane review first published in 2001, and previously updated in 2006 and 2011. OBJECTIVES To evaluate the effectiveness and safety of gonadotrophin-releasing hormone (GnRH) antagonists compared with the standard long protocol of GnRH agonists for controlled ovarian hyperstimulation in assisted conception cycles. SEARCH METHODS We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched from inception to May 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, inception to 28 April 2015), Ovid MEDLINE (1966 to 28 April 2015), EMBASE (1980 to 28 April 2015), PsycINFO (1806 to 28 April 2015), CINAHL (to 28 April 2015) and trial registers to 28 April 2015, and handsearched bibliographies of relevant publications and reviews, and abstracts of major scientific meetings, for example the European Society of Human Reproduction and Embryology (ESHRE) and American Society for Reproductive Medicine (ASRM). We contacted the authors of eligible studies for missing or unpublished data. The evidence is current to 28 April 2015. SELECTION CRITERIA Two review authors independently screened the relevant citations for randomised controlled trials (RCTs) comparing different GnRH agonist versus GnRH antagonist protocols in women undergoing in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI). DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility and risk of bias, and extracted the data. The primary review outcomes were live birth and ovarian hyperstimulation syndrome (OHSS). Other adverse effects (miscarriage and cycle cancellation) were secondary outcomes. We combined data to calculate pooled odds ratios (ORs) and 95% confidence intervals (CIs). Statistical heterogeneity was assessed using the I(2) statistic. We assessed the overall quality of the evidence for each comparison using GRADE methods. MAIN RESULTS We included 73 RCTs, with 12,212 participants, comparing GnRH antagonist to long-course GnRH agonist protocols. The quality of the evidence was moderate: limitations were poor reporting of study methods.Live birthThere was no conclusive evidence of a difference in live birth rate between GnRH antagonist and long course GnRH agonist (OR 1.02, 95% CI 0.85 to 1.23; 12 RCTs, n = 2303, I(2)= 27%, moderate quality evidence). The evidence suggested that if the chance of live birth following GnRH agonist is assumed to be 29%, the chance following GnRH antagonist would be between 25% and 33%.OHSSGnRH antagonist was associated with lower incidence of any grade of OHSS than GnRH agonist (OR 0.61, 95% C 0.51 to 0.72; 36 RCTs, n = 7944, I(2) = 31%, moderate quality evidence). The evidence suggested that if the risk of OHSS following GnRH agonist is assumed to be 11%, the risk following GnRH antagonist would be between 6% and 9%.Other adverse effectsThere was no evidence of a difference in miscarriage rate per woman randomised between GnRH antagonist group and GnRH agonist group (OR 1.04, 95% CI 0.82 to 1.30; 33 RCTs, n = 7022, I(2) = 0%, moderate quality evidence).With respect to cycle cancellation, GnRH antagonist was associated with a lower incidence of cycle cancellation due to high risk of OHSS (OR 0.47, 95% CI 0.32 to 0.69; 19 RCTs, n = 4256, I(2) = 0%). However cycle cancellation due to poor ovarian response was higher in women who received GnRH antagonist than those who were treated with GnRH agonist (OR 1.32, 95% CI 1.06 to 1.65; 25 RCTs, n = 5230, I(2) = 68%; moderate quality evidence). AUTHORS' CONCLUSIONS There is moderate quality evidence that the use of GnRH antagonist compared with long-course GnRH agonist protocols is associated with a substantial reduction in OHSS without reducing the likelihood of achieving live birth.
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Affiliation(s)
- Hesham G Al‐Inany
- Faculty of Medicine, Cairo UniversityDepartment of Obstetrics & Gynaecology8 Moustapha Hassanin StManialCairoEgypt
| | - Mohamed A Youssef
- Faculty of Medicine, Cairo UniversityDepartment of Obstetrics & Gynaecology8 Moustapha Hassanin StManialCairoEgypt
| | - Reuben Olugbenga Ayeleke
- University of AucklandDepartment of Obstetrics and GynaecologyPrivate Bag 92019AucklandNew Zealand
| | - Julie Brown
- The University of AucklandLiggins InstitutePark RdGraftonAucklandNew Zealand1142
| | - Wai Sun Lam
- University of AucklandDepartment of Obstetrics and GynaecologyPrivate Bag 92019AucklandNew Zealand
| | - Frank J Broekmans
- University Medical CenterDepartment of Reproductive Medicine and GynecologyUtrechtNetherlands
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Ou J, Xing W, Li Y, Xu Y, Zhou C. Short versus Long Gonadotropin-Releasing Hormone Analogue Suppression Protocols in IVF/ICSI Cycles in Patients of Various Age Ranges. PLoS One 2015. [PMID: 26208150 PMCID: PMC4514806 DOI: 10.1371/journal.pone.0133887] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Objective To compare the two GnRH-a protocols (long GnRH-a protocol and short GnRH-a protocol) for ovarian stimulation in IVF/ICSI cycles in patients of various age ranges. Methods A total of 5662 IVF-ET/ICSI cycles from 2010 to 2013 were retrospectively identified. The cycles were divided into two groups: a long protocol group and short protocol group. In each group, the patients were divided into four age ranges: <31 years, 31 to 35 years, 36 to 40 years, and >40 years. The duration of stimulation, total dose of Gn, implantation rate and pregnancy rate were compared. Results The total dose of Gn was significantly higher, and the duration of stimulation was significantly longer, in the long protocol group than in the short protocol group for all age ranges (P<0.05). If the patients were of the same age range, the number of oocytes retrieved, MII oocytes, and high-quality embryos in the long protocol group were all significantly greater than those in the short protocol group (P<0.05). In the long protocol group, the clinical pregnancy rates of the four age ranges were 52.76%, 44.33%, 36.15% and 13.33%, respectively, which were significantly higher than those in the short protocol group (33.33%, 24.58%, 22.49% and 8.72%, respectively; P<0.05). The same trend was also found in the implantation rates of the four age ranges. As the age increased, the clinical pregnancy and implantation rates, as well as the number of oocytes retrieved, MII oocytes, and high-quality embryos, of the long protocol group significantly decreased (P<0.05). Conclusions Our study demonstrated that regardless of patient age, the long protocol was superior to the short protocol in terms of the number of retrieved oocytes, as well as the implantation and pregnancy rates.
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Affiliation(s)
- Jianping Ou
- Center for Reproductive Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Weijie Xing
- Center for Reproductive Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yubin Li
- Center for Reproductive Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yanwen Xu
- Center for Reproductive Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Canquan Zhou
- Center for Reproductive Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- * E-mail:
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Gervais A, Battista MC, Carranza-Mamane B, Lavoie HB, Baillargeon JP. Follicular fluid concentrations of lipids and their metabolites are associated with intraovarian gonadotropin-stimulated androgen production in women undergoing in vitro fertilization. J Clin Endocrinol Metab 2015; 100:1845-54. [PMID: 25695883 DOI: 10.1210/jc.2014-3649] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
CONTEXT Although growing evidence points toward a role of lipotoxicity in the development of hyperandrogenesis, the main feature of polycystic ovary syndrome, few studies directly assessed this association in vivo in humans, and none targeted the ovarian milieu. OBJECTIVE The main objective of this study was to correlate follicular fluid (FF) T levels with lipids, lipid metabolites, and inflammation markers. DESIGN This was a cross-sectional study. SETTING Recruitment was performed in two fertility clinics at one private and one academic center. PARTICIPANTS Eighty women requiring in vitro fertilization were recruited during one of their scheduled visit at the fertility clinic. All women aged between 18 and 40 years with a body mass index between 18 and 40 kg/m(2) were invited to participate. INTERVENTION(S) There were no interventions. MAIN OUTCOME MEASURE(S) At the time of oocyte aspiration, FF was collected and analyzed for total T, lipids [nonesterified fatty acids (NEFAs) plus triglycerides], NEFA metabolites (acylcarnitines; markers of ineffective NEFAs β-oxidation), and inflammatory marker composition. The hypothesis being tested was formulated before the data collection. RESULTS FF T levels were significantly correlated with FF levels of lipids (r = 0.381, P = .001; independently of IL-6), acylcarnitines (r ≥ 0.255, all P = .008; not independently of lipids), and IL-6 (r = 0.300, P = .009, independently of lipids). Additionally, FF lipid levels were significantly and strongly correlated with acylcarnitines (r ≥ 0.594; all P < .001). CONCLUSIONS These results suggest that ovarian androgen production is related to intraovarian exposure to lipids, independently of inflammation and mainly through ineffective NEFA β-oxidation (as shown by higher acylcarnitine levels). Inflammation is also associated with intraovarian androgenesis, independently of lipids.
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Affiliation(s)
- A Gervais
- Division of Endocrinology (A.G., M.-C.B., J.-P.B.), Department of Medicine, and Department of Obstetrics and Gynecology (B.C.-M.), Université de Sherbrooke, and Centre de Recherche Clinique Étienne-LeBel (B.C.-M., J.-P.B.), Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada J1H 5N4; and PROCREA Cliniques (B.C.-M.), Mt Royal, Québec, Canada H3P 2W3
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Nastri CO, Teixeira DM, Moroni RM, Leitão VMS, Martins WP. Ovarian hyperstimulation syndrome: pathophysiology, staging, prediction and prevention. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:377-93. [PMID: 25302750 DOI: 10.1002/uog.14684] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 09/25/2014] [Accepted: 09/29/2014] [Indexed: 05/25/2023]
Abstract
OBJECTIVE To identify, appraise and summarize the current evidence regarding the pathophysiology, staging, prediction and prevention of ovarian hyperstimulation syndrome (OHSS). METHODS Two comprehensive systematic reviews were carried out: one examined methods of predicting either high ovarian response or OHSS and the other examined interventions aimed at reducing the occurrence of OHSS. Additionally, we describe the related pathophysiology and staging criteria. RESULTS Seven studies examining methods of predicting OHSS and eight more examining methods of predicting high ovarian response to controlled ovarian stimulation were included. Current evidence shows that the best methods of predicting high response are antral follicle count and anti-Müllerian hormone levels, and that a high ovarian response (examined by the number of large follicles, estradiol concentration or the number of retrieved oocytes) is the best method of predicting the occurrence of OHSS. Ninety-seven randomized controlled trials examining the effect of several interventions for reducing the occurrence of OHSS were included. There was high-quality evidence that replacing human chorionic gonadotropin by gonadotropin-releasing hormone agonists or recombinant luteinizing hormone, and moderate-quality evidence that antagonist protocols, dopamine agonists and mild stimulation, reduce the occurrence of OHSS. The evidence for the effect of the other interventions was of low/very low quality. Additionally, we identified and described 12 different staging criteria. CONCLUSIONS There are useful predictive tools and several preventive interventions aimed at reducing the occurrence of OHSS. Acknowledging and understanding them are of crucial importance for planning the treatment of, and, ultimately, eliminating, OHSS while maintaining high pregnancy rates.
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Affiliation(s)
- C O Nastri
- Department of Obstetrics and Gynecology, Ribeirao Preto Medical School, University of Sao Paulo (DGO-FMRP-USP), Ribeirao Preto, Brazil; School of Health Technology - Ultrasonography School of Ribeirao Preto (FATESA-EURP), Ribeirao Preto, Brazil
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Liu Y, Chapple V, Roberts P, Matson P. Prevalence, consequence, and significance of reverse cleavage by human embryos viewed with the use of the Embryoscope time-lapse video system. Fertil Steril 2014; 102:1295-1300.e2. [PMID: 25225070 DOI: 10.1016/j.fertnstert.2014.07.1235] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 07/09/2014] [Accepted: 07/14/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate the prevalence and potential causes of reverse cleavage (RC) by human early-cleavage embryos and its associations with embryonic development and implantation after transfer. DESIGN Clinical retrospective cohort study. SETTING Private fertility treatment center. PATIENT(S) A total of 126 consecutive in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) treatment cycles, with 353 IVF and 436 ICSI embryos cultured in the Embryoscope until day 3. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Embryo assessment on day 3, incidence of abnormal division, embryo morphokinetic parameters, and fetal heart beat. RESULT(S) RC, referring to either blastomere fusion or failed cytokinesis, occurred up to three times per individual embryo in 27.4% of embryos during the first three cleavage cycles. A higher incidence was associated with GnRH antagonist cycles compared with agonist cycles (odds ratio [OR] 1.683), or with ICSI compared with IVF (OR 1.600). After ICSI, sperm progressive motility was associated with RC (area under the receiver operating characteristic curve: 0.573). Compared with RC-negative embryos, a lower proportion of RC-positive embryos reached 6-cell stage or beyond by day 3 (47.7% vs. 71.7%), and were more likely to have multinucleation at the 4-cell stage (10.1% vs. 5.0%). Embryos showing RC had significantly poorer performance in both conventional grading and morphokinetic parameters, and they implanted less (0/22 vs. 29/131) than those not showing RC. CONCLUSION(S) RC significantly compromised embryo development, culminating in poor implantation potential. For each embryo, it can occur on more than one occasion at any stage during the first 3 days of culture. It is associated with factors affecting both oocyte and sperm.
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Affiliation(s)
- Yanhe Liu
- Fertility North, Joondalup Health Campus, Joondalup, Western Australia, Australia; School of Medical Sciences, Edith Cowan University, Joondalup, Western Australia, Australia.
| | - Vincent Chapple
- Fertility North, Joondalup Health Campus, Joondalup, Western Australia, Australia
| | - Peter Roberts
- School of Medical Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Phillip Matson
- Fertility North, Joondalup Health Campus, Joondalup, Western Australia, Australia; School of Medical Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
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