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Vaiarelli A, Ruffa A, Cerrillo M, García-Velasco JA. GnRH agonist trigger in poor prognosis patients undergoing a multicycle approach through DuoStim or consecutive stimulations: a SWOT analysis. Curr Opin Obstet Gynecol 2024; 36:124-133. [PMID: 38597577 DOI: 10.1097/gco.0000000000000947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
PURPOSE OF REVIEW Identify the most recent and significant evidence regarding the ovulation trigger within the framework of a multicycle approach through DuoStim, providing valuable insights for improving treatment strategies in patients with a poor prognosis. RECENT FINDINGS The trigger method plays a pivotal role in optimizing in-vitro fertilization (IVF) stimulation, influencing oocyte retrieval and maturation rates, as well as follicle recruitment in consecutive ovarian stimulations such as double stimulation. Decision-making involves multiple factors and, while guidelines exist for conventional stimulation, specific recommendations for the multicycle approach are not well established. SUMMARY The different methods for inducing oocyte maturation underscore the need for personalization of IVF protocols. The GnRH agonist trigger induces rapid luteolysis and establishes favorable hormonal conditions that do not adversely affect the recruitment of consecutive follicular waves in the context of DuoStim. It serves as a valid alternative to hCG in freeze-all cycles. This strategy might enhance the safety and flexibility of ovarian stimulations with no impact on oocyte competence and IVF efficacy.
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Affiliation(s)
- Alberto Vaiarelli
- IVIRMA Global Research Alliance, GENERA, Clinica Valle Giulia, Rome, Italy
| | - Alessandro Ruffa
- IVIRMA Global Research Alliance, GENERA, Clinica Valle Giulia, Rome, Italy
| | - María Cerrillo
- IVIRMA Global Research Alliance, IVIRMA Madrid, Madrid, Spain
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Boudry L, Mateizel I, Wouters K, Papaleo E, Mackens S, De Vos M, Racca A, Adriaenssens T, Tournaye H, Blockeel C. Does dual oocyte retrieval with continuous FSH administration increase the number of mature oocytes in low responders? An open-label randomized controlled trial. Hum Reprod 2024; 39:538-547. [PMID: 38199789 DOI: 10.1093/humrep/dead276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 11/21/2023] [Indexed: 01/12/2024] Open
Abstract
STUDY QUESTION Is there an increase in the total number of metaphase II (MII) oocytes between a conventional ovarian stimulation (OS) and a double uninterrupted stimulation? SUMMARY ANSWER There is no increase in the total number of MII oocytes when comparing one conventional OS to a continuous stimulation with double oocyte aspiration. WHAT IS KNOWN ALREADY Based on the concept of multiple follicular waves, the combination of two stimulations in the same ovarian cycle has gained interest in patients with a low ovarian reserve. This so-called dual stimulation approach is usually characterized by a discontinuation of FSH administration for ∼5 days and appears to have a favourable impact on the number of retrieved oocytes without affecting the embryo quality or ploidy status. The outcomes of dual uninterrupted OS have not yet been studied. STUDY DESIGN, SIZE, DURATION This was an open-label randomized controlled trial (RCT) with superiority design, performed in a single tertiary centre. Subjects were randomized with a 1:1 allocation into two groups between October 2019 and September 2021. All patients underwent a conventional stimulation with recombinant FSH. When two or more follicles of 17 mm were present, the final inclusion criterion was assessed; randomization occurred only in the presence of ≤9 follicles of ≥11 mm. In Group A, ovulation was triggered with hCG, and oocyte retrieval (OR) was performed 34-36 h later, followed by a fresh single or double embryo transfer (SET or DET) on Day 3/5. In Group B, ovulation was triggered with GnRH agonist, followed by another OS, without discontinuation of the FSH administration. In the presence of one or more follicles of ≥17 mm, the second stimulation was completed with hCG. A freeze-all strategy (Day 3/5) was applied for both retrievals, followed by transfer of one or two embryos in an artificially prepared frozen-thawed cycle. In the absence of one or more follicles of ≥17 mm after 13 additional days of stimulation, the second cycle was cancelled. All ORs were executed by a senior fertility specialist who was blinded for the first treatment, and all follicles >10 mm were aspirated, according to routine clinical practice. The primary outcome was the total number of MII oocytes. Patients were followed up until all embryos were transferred, or until live birth was achieved. Other secondary outcomes included the number of cumulus-oocyte complexes (COCs), the number of good quality embryos (Day 3/5), the ongoing pregnancy rate, and gonadotropin consumption. PARTICIPANTS/MATERIALS, SETTING, METHODS Patients between 25 and 40 years old, with an anti-Müllerian hormone level of ≤1.5 ng/ml, antral follicle count of ≤6, or ≤5 oocytes after a previous stimulation, were included. At the start, 70 patients were eligible for participation in the trial, of whom 48 patients fulfilled the final inclusion criterium and were randomized. After drop-out of two patients, 23 patients were randomized to a single round of OS (Group A), and 23 patients were randomized to two uninterrupted rounds of OS (Group B). MAIN RESULTS AND THE ROLE OF CHANCE Baseline characteristics were similar between both groups. The cumulative number of COCs and MII oocytes after completion of the second OR was similar in Group A and Group B [5.3 ± 2.7 versus 5.3 ± 3.0 (P = 0.95); 4.1 ± 2.4 versus 4.3 ± 2.7 (P = 0.77)]. Likewise, a comparable number of excellent and good quality embryos was available on Day 3 (3.0 ± 2.0 versus 2.7 ± 2.0; P = 0.63). In Group B, the cancellation rate due to insufficient response to the second round of stimulation was 39.1% (9/23). When focusing on the first stimulation in both groups, there were no significant differences regarding basal FSH, gonadotropin consumption, and the number of preovulatory follicles. After the first OR, the mean number of COC and MII oocytes was significantly higher in Group A (who had hCG triggering), compared to Group B (who had GnRH agonist triggering) [5.3 ± 2.7 versus 3.3 ± 2.2; difference 95% CI (0.54 to 3.45), P = 0.004 and 4.1 ± 2.4 versus 3.0 ± 2.2; difference 95% CI (-0.15 to 2.6), P = 0.05, respectively]. Likewise, the number of excellent and good quality embryos on Day 3 was significantly higher (3.0 ± 2.0 versus 1.9 ± 1.7; P = 0.02) in Group A. LIMITATIONS, REASONS FOR CAUTION This study was powered to demonstrate superiority for the number of MII oocytes after dual stimulation. Investigating the impact of dual stimulation on pregnancy rates would have required a larger sample size. Furthermore, the heterogeneity in embryo vitrification and transfer policies precluded a correct comparison of embryologic outcomes between both groups. WIDER IMPLICATIONS OF THE FINDINGS This is the first RCT investigating the role of continuous stimulation with double aspiration in low responders. Our results show no statistically significant differences in the cumulative number of MII oocytes between one conventional stimulation with fresh ET and two consecutive stimulations with a freeze-only approach. Furthermore, the observed suboptimal oocyte yield after agonist ovulation triggering in low responders in the dual uninterrupted OS group is a reason for concern and further scrutiny, given that previous RCTs have shown similar outcomes in normal and high responders after hCG and GnRH agonist triggers. STUDY FUNDING/COMPETING INTEREST(S) This work was supported in part by a research grant from Organon. H.T. received honoraria for lectures and presentations from Abbott, Cooper Surgical, Gedeon-Richter, Cook, Goodlife, and Ferring. L.B. received fees for lectures from Merck & Organon and support for attending ESHRE 2023. M.D.V. reports fees for lectures from Ferring, Merck, Organon, IBSA, Gedeon Richter, and Cooper Surgical and support for attending ASRM 2023. S.M. received honoraria for lectures and presentations from Abbott, Cooper Surgical, Gedeon-Richter, IBSA, and Merck. C.B. was on the Advisory board and received consulting fees from Theramex and received honoraria for lectures and presentations from Abbott, Ferring, Gedeon-Richter, IBSA, and Merck. TRIAL REGISTRATION NUMBER NCT03846544. TRIAL REGISTRATION DATE 19 February 2019. DATE OF FIRST PATIENT’S ENROLMENT 28 October 2019.
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Affiliation(s)
- L Boudry
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - I Mateizel
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - K Wouters
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - E Papaleo
- Obstetrics and Gynaecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - S Mackens
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - M De Vos
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - A Racca
- Department of Gynaecology and Reproductive Medicine, Instituto Bernabeu Venezia, Venezia, Italy
| | - T Adriaenssens
- Laboratory of Follicle Biology, Vrije Universiteit Brussel, Brussels, Belgium
| | - H Tournaye
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - C Blockeel
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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Li M, Han J, Yang N, Li X, Wu X. Transcriptome profiling reveals superovulation with the gonadotropin-releasing hormone agonist trigger impaired embryo implantation in mice. Front Endocrinol (Lausanne) 2024; 15:1354435. [PMID: 38469140 PMCID: PMC10925639 DOI: 10.3389/fendo.2024.1354435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/29/2024] [Indexed: 03/13/2024] Open
Abstract
Introduction Superovulation is a critical step in assisted reproductive technology, but the use of human chorionic gonadotropin (hCG) as a trigger for superovulation can result in ovarian hyperstimulation. Thus, the use of Gonadotropin-releasing hormone agonist (GnRHa) trigger has been increasingly adopted, although it has been associated with a higher rate of pregnancy failure compared to natural cycles. This study aimed to investigate the effect of GnRHa trigger on embryo implantation in a mouse model. Methods Mice in the superovulation (PG) group were administered 7.5 IU of PMSG, followed by the injection of 3.5 μg of GnRHa (Leuprorelin) 48 h later, while mice in the control group (CTR) mated naturally. We compared the number of oocytes, blastocysts, and corpus luteum between the two groups and the implantation sites after the transfer of natural blastocysts. Ovaries, uterus, and serum 2 and 4 days after mating were collected for qRT-PCR, transcriptome sequencing, and hormone assays. Results The PG group had more oocytes, blastocysts, and corpus luteum after superovulation than the CTR group. However, the mRNA expression of leukemia inhibitory factor (Lif) and the number of implantation sites were reduced in the PG group. The ELISA assay revealed that superovulation increased ovarian estrogen secretion. The transcriptome analysis showed that superphysiological estrogen led to a response of the uterus to a high estrogen signal, resulting in abnormal endometrium and extracellular matrix remodeling and up-regulation of ion transport and inflammation-related genes. Conclusion Our findings suggest that a combination of PMSG and GnRHa trigger impaired embryo implantation in mice, as the excessive uterine response to superphysiological estrogen levels can lead to the change of gene expression related to endometrial remodeling, abnormal expression of uterine ion transport genes and excessive immune-related genes.
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Affiliation(s)
- Meng Li
- College of Animal Science and Technology, Hebei Technology Innovation Center of Cattle and Sheep Embryo, Hebei Agricultural University, Baoding, China
| | - Jingmei Han
- College of Veterinary Medicine, Hebei Agricultural University, Baoding, China
| | - Nana Yang
- College of Animal Science and Technology, Hebei Technology Innovation Center of Cattle and Sheep Embryo, Hebei Agricultural University, Baoding, China
| | - Xiangyun Li
- College of Animal Science and Technology, Hebei Technology Innovation Center of Cattle and Sheep Embryo, Hebei Agricultural University, Baoding, China
| | - Xinglong Wu
- College of Animal Science and Technology, Hebei Technology Innovation Center of Cattle and Sheep Embryo, Hebei Agricultural University, Baoding, China
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Massarotti C, Stigliani S, Gazzo I, Lambertini M, Anserini P. Re: Safety and efficacy concerns of long-acting GnRH agonist trigger for ovulation induction in oncological patients undergoing oocyte cryopreservation: a call for caution and further investigation. ESMO Open 2023; 8:101826. [PMID: 37717388 PMCID: PMC10514091 DOI: 10.1016/j.esmoop.2023.101826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 08/25/2023] [Indexed: 09/19/2023] Open
Affiliation(s)
- C Massarotti
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI Dept.), University of Genoa, Genoa; Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa.
| | - S Stigliani
- Physiopathology of Human Reproduction Unit, IRCCS Ospedale Policlinico San Martino, Genoa
| | - I Gazzo
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI Dept.), University of Genoa, Genoa; Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa
| | - M Lambertini
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genoa; Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - P Anserini
- Physiopathology of Human Reproduction Unit, IRCCS Ospedale Policlinico San Martino, Genoa
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Massarotti C, Stigliani S, Gazzo I, Lambertini M, Anserini P. Long-acting gonadotropin-releasing hormone agonist trigger in fertility preservation cycles before chemotherapy. ESMO Open 2023; 8:101597. [PMID: 37421801 PMCID: PMC10485390 DOI: 10.1016/j.esmoop.2023.101597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 05/25/2023] [Accepted: 06/11/2023] [Indexed: 07/10/2023] Open
Abstract
BACKGROUND Oocytes/embryo cryopreservation and ovarian function suppression with gonadotropin-releasing hormone (GnRH) agonists (GnRHas) are two established strategies for preserving fertility in patients with cancer, frequently both being offered to the same woman. As the first injection of GnRHa should be administered before chemotherapy, it is usually performed in the luteal phase of the urgent controlled ovarian stimulation (COS) cycle. The GnRHa flare-up effect on recently stimulated ovaries may cause ovarian hyperstimulation syndrome (OHSS) and this risk may discourage some oncologists to offer an ovarian function preservation method with proven efficacy. We suggest the long-acting GnRHa as an option to trigger ovulation for egg retrieval in oncological patients, whenever ovarian suppression during chemotherapy is planned. PATIENTS AND METHODS We retrospectively analyzed prospectively collected data from all consecutive ovarian stimulation cases in oncological patients for oocyte cryopreservation from 2016 to 2021 in a single academic referral center. The COS was performed according to good clinical practice standards. Since 2020 long-acting GnRHa trigger was offered to all patients for whom ovarian suppression after cryopreservation was planned. All other patients served as controls, stratified for the triggering method used: highly purified chorionic gonadotrophin 10 000 UI or short-acting GnRHa 0.2 mg. RESULTS Mature oocytes were collected, with the expected maturation rate, in all the 22 cycles triggered with GnRHa. The mean number of cryopreserved oocytes was 11.1 ± 4, with a maturation rate of 80% (57%-100%), versus 8.8 ± 5.8, 74% (33%-100%) with highly purified chorionic gonadotrophin and 14 ± 8.4, 80% (44%-100%) with short-acting GnRHa. No case of OHSS was observed after long-acting GnRHa triggering and by 5 days after egg retrieval most patients had reached luteinizing hormone levels showing suppression. CONCLUSIONS Our preliminary data show that long-acting GnRHa is efficacious in inducing the final oocytes' maturation, reducing OHSS risk and suppressing ovarian function by the start of chemotherapy.
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Affiliation(s)
- C Massarotti
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI Department), University of Genoa, Genoa; Maternal and Child Department, Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa.
| | - S Stigliani
- Maternal and Child Department, Physiopathology of Human Reproduction Unit, IRCCS Ospedale Policlinico San Martino, Genoa
| | - I Gazzo
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI Department), University of Genoa, Genoa; Maternal and Child Department, Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa
| | - M Lambertini
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genoa, Genoa; Department of Medical Oncology, UO Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - P Anserini
- Maternal and Child Department, Physiopathology of Human Reproduction Unit, IRCCS Ospedale Policlinico San Martino, Genoa
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Fuentes A, García-Ajofrín C, Romero R, Castillo JC, Ortíz JA, Hortal M, Guerrero J, Bernabeu A, Bernabeu R. Influence of the starting day of luteal phase stimulation on double stimulation cycles. Front Endocrinol (Lausanne) 2023; 14:1216671. [PMID: 37529596 PMCID: PMC10390300 DOI: 10.3389/fendo.2023.1216671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 06/21/2023] [Indexed: 08/03/2023] Open
Abstract
Background Double ovarian stimulation is one of the most used strategies in poor-prognosis patients. There is a high heterogeneity between the studies regarding the execution of this stimulation protocol. The aim of this study was to investigate whether the day on which luteal phase stimulation begins after the first oocyte retrieval affects ovarian response in DuoStim cycles. Methods This observational and retrospective study included 541 DuoStim cycles between January 2018 and December 2021 in a private fertility clinic. Patients were assigned to 4 groups according to the timing of the onset of luteal phase stimulation after oocyte retrieval (0-2nd day, 3rd day, 4th day and 5th-6th day). The primary outcome was the number of oocytes retrieved in the luteal phase in each group. Results No differences were found between groups in the number of oocytes collected (5.12 ± 3.56 vs. 5.39 ± 3.74 vs. 5.61 ± 3.94 vs. 5.89 ± 3.92; p=0,6), MII or number of follicles. An increase in the duration of stimulation was found when stimulation started on the 4th day (10.42 ± 2.31 vs. 10.68 ± 2.37 vs. 11.27 ± 2.40 vs. 10.65 ± 2.37 days, p=0,033). A lower number of fertilized oocytes was observed when stimulation began before the fourth day (3.36 ± 2.80 vs. 3.95 ± 2.53 vs. 4.03 ± 2.73 vs. 4.48 ± 3.11; p=0,036). The number of blastocysts was higher when the stimulation started 5-6 days after retrieval (1.82 ± 1.74 vs. 2.13 ± 1.61 vs. 2.33 ± 2.06 vs. 2.91 ± 2.39; p= 0,030). Discussion The number of oocytes retrieved does not differ depending on the day that stimulation begins. However, oocytes competence in terms of fertilized oocytes and blastulation, appears to be lower when the second stimulation starts before the fourth day after oocyte retrieval.
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Affiliation(s)
- Ana Fuentes
- Department of Reproductive Medicine, Instituto Bernabeu, Alicante, Spain
| | | | - Ruth Romero
- Department of Reproductive Medicine, Instituto Bernabeu Madrid, Madrid, Spain
| | - Juan Carlos Castillo
- Department of Reproductive Medicine, Instituto Bernabeu, Alicante, Spain
- Cátedra de Medicina Comunitaria y Salud Reproductiva, Universidad Miguel Hernández, Elche, Spain
| | - Jose A. Ortíz
- Department of Molecular Biology, Instituto Bernabeu BIOTECH, Alicante, Spain
| | - Mónica Hortal
- Department of Molecular Biology, Instituto Bernabeu BIOTECH, Alicante, Spain
| | - Jaime Guerrero
- Department of Embryology, Instituto Bernabeu, Alicante, Spain
| | - Andrea Bernabeu
- Department of Reproductive Medicine, Instituto Bernabeu, Alicante, Spain
- Cátedra de Medicina Comunitaria y Salud Reproductiva, Universidad Miguel Hernández, Elche, Spain
| | - Rafael Bernabeu
- Department of Reproductive Medicine, Instituto Bernabeu, Alicante, Spain
- Cátedra de Medicina Comunitaria y Salud Reproductiva, Universidad Miguel Hernández, Elche, Spain
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Zhao W, Diao H, Chen X, Xu S, Jiang S, Cao H, Zhang C, Zhang Y. The serum oestradiol/progesterone ratio on the day of OPU + 7, but not the day of OPU + 5, affects the rates of live birth in fresh blastocyst embryo transfer cycles. J Ovarian Res 2023; 16:4. [PMID: 36611200 PMCID: PMC9826588 DOI: 10.1186/s13048-023-01096-3] [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: 10/12/2022] [Accepted: 01/03/2023] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND In an in vitro fertilization (IVF) cycle, the embryo ends its wandering time and begins the process of implantation into the uterine cavity on the seventh day after oocyte pick-up (OPU + 7), which is closer than OPU + 5 to the time of nidation. Therefore, measuring the oestradiol (E2)/progesterone (P) ratio on OPU + 7 may be helpful for predicting pregnancy outcomes. METHODS This is a retrospective cohort study of 2,257 women undergoing a follicular-phase depot gonadotropin-releasing hormone agonist (GnRH-a) protocol for in vitro fertilization /intracytoplasmic sperm injection (IVF/ICSI) treatment and fresh blastocyst embryo transfer cycles at a university-affiliated fertility center between January 2016 and April 2021. First, 2,257 women were split into two groups based on clinical pregnancy for analyzing the levels of E2 and P and the E2/P ratio on the day of OPU + 2, OPU + 5 and OPU + 7. And then 2,257 cycles were stratified into three groups based on E2/P ratio tertiles on OPU + 7: the low group (1.3-15.7 pg/ng), middle group (15.7-28.8 pg/ng), and high group (28.8-487.2 pg/ng). The threshold effect of the E2/P ratio on OPU + 7 on live birth was investigated using a two-piecewise linear regression model and a smoothing function curve. RESULTS The level of P in the clinical pregnancy group were lower than that in the nonclinical pregnancy group on both OPU + 2 and OPU + 7 (201.9 ± 71.6 ng/ml vs 213.1 ± 77.6 ng/ml, 89.5 ± 88.5 ng/ml vs 99.5 ± 94.9 ng/ml, P < 0.05). The E2/P ratio in the clinical pregnancy group were higher than that in the nonclinical pregnancy group on both OPU + 2 and OPU + 7 (8.4 ± 6.5 pg/ng vs 8.0 ± 6.8 pg/ng, 32.3 ± 38.5 pg/ng vs 25.2 ± 31.0 pg/ng, P < 0.01). The E2/P ratio on OPU + 7 was positively associated with positive hCG (adjusted OR = 1.01; 95% CI, 1.01-1.02; P < 0.0001), clinical pregnancy (adjusted OR = 1.01; 95% CI, 1.00-1.01; P = 0.0067) and live birth (adjusted OR = 1.01; 95% CI, 1.00-1.01; P < 0.001), and a nonlinear correlation was observed between the E2/P ratio and LBR on OPU + 7. CONCLUSIONS A higher E2/P ratio is associated with a higher LBR, but the E2/P ratio should be maintained within a suitable range.
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Affiliation(s)
- Wenxian Zhao
- grid.443573.20000 0004 1799 2448Reproductive Medicine Centre, Renmin Hospital, Hubei University of Medicine, Shiyan, People’s Republic of China ,Hubei Clinical Research Centre for Reproductive Medicine, Shiyan, People’s Republic of China
| | - Honglu Diao
- grid.443573.20000 0004 1799 2448Reproductive Medicine Centre, Renmin Hospital, Hubei University of Medicine, Shiyan, People’s Republic of China ,Hubei Clinical Research Centre for Reproductive Medicine, Shiyan, People’s Republic of China ,grid.443573.20000 0004 1799 2448Biomedical Engineering College, Hubei University of Medicine, Shiyan, People’s Republic of China ,grid.443573.20000 0004 1799 2448Biomedical Research Institute, Hubei University of Medicine, Shiyan, People’s Republic of China ,grid.443573.20000 0004 1799 2448Hubei Key Laboratory of Embryonic Stem Cell Research, Hubei University of Medicine, Shiyan, People’s Republic of China
| | - Xin Chen
- grid.443573.20000 0004 1799 2448Reproductive Medicine Centre, Renmin Hospital, Hubei University of Medicine, Shiyan, People’s Republic of China ,Hubei Clinical Research Centre for Reproductive Medicine, Shiyan, People’s Republic of China ,grid.443573.20000 0004 1799 2448Biomedical Engineering College, Hubei University of Medicine, Shiyan, People’s Republic of China ,grid.443573.20000 0004 1799 2448Biomedical Research Institute, Hubei University of Medicine, Shiyan, People’s Republic of China ,grid.443573.20000 0004 1799 2448Hubei Key Laboratory of Embryonic Stem Cell Research, Hubei University of Medicine, Shiyan, People’s Republic of China
| | - Shaoyuan Xu
- grid.443573.20000 0004 1799 2448Reproductive Medicine Centre, Renmin Hospital, Hubei University of Medicine, Shiyan, People’s Republic of China ,Hubei Clinical Research Centre for Reproductive Medicine, Shiyan, People’s Republic of China ,grid.443573.20000 0004 1799 2448Biomedical Engineering College, Hubei University of Medicine, Shiyan, People’s Republic of China ,grid.443573.20000 0004 1799 2448Biomedical Research Institute, Hubei University of Medicine, Shiyan, People’s Republic of China ,grid.443573.20000 0004 1799 2448Hubei Key Laboratory of Embryonic Stem Cell Research, Hubei University of Medicine, Shiyan, People’s Republic of China
| | - Shengfang Jiang
- grid.443573.20000 0004 1799 2448Reproductive Medicine Centre, Renmin Hospital, Hubei University of Medicine, Shiyan, People’s Republic of China ,Hubei Clinical Research Centre for Reproductive Medicine, Shiyan, People’s Republic of China ,grid.443573.20000 0004 1799 2448Biomedical Engineering College, Hubei University of Medicine, Shiyan, People’s Republic of China ,grid.443573.20000 0004 1799 2448Biomedical Research Institute, Hubei University of Medicine, Shiyan, People’s Republic of China ,grid.443573.20000 0004 1799 2448Hubei Key Laboratory of Embryonic Stem Cell Research, Hubei University of Medicine, Shiyan, People’s Republic of China
| | - Hong Cao
- grid.443573.20000 0004 1799 2448Department of Orthopaedic Surgery, Renmin Hospital, Hubei University of Medicine, Shiyan, People’s Republic of China
| | - Changjun Zhang
- grid.443573.20000 0004 1799 2448Reproductive Medicine Centre, Renmin Hospital, Hubei University of Medicine, Shiyan, People’s Republic of China ,Hubei Clinical Research Centre for Reproductive Medicine, Shiyan, People’s Republic of China ,grid.443573.20000 0004 1799 2448Biomedical Engineering College, Hubei University of Medicine, Shiyan, People’s Republic of China ,grid.443573.20000 0004 1799 2448Biomedical Research Institute, Hubei University of Medicine, Shiyan, People’s Republic of China ,grid.443573.20000 0004 1799 2448Hubei Key Laboratory of Embryonic Stem Cell Research, Hubei University of Medicine, Shiyan, People’s Republic of China
| | - Ying Zhang
- grid.443573.20000 0004 1799 2448Reproductive Medicine Centre, Renmin Hospital, Hubei University of Medicine, Shiyan, People’s Republic of China ,Hubei Clinical Research Centre for Reproductive Medicine, Shiyan, People’s Republic of China ,grid.443573.20000 0004 1799 2448Biomedical Engineering College, Hubei University of Medicine, Shiyan, People’s Republic of China ,grid.443573.20000 0004 1799 2448Biomedical Research Institute, Hubei University of Medicine, Shiyan, People’s Republic of China ,grid.443573.20000 0004 1799 2448Hubei Key Laboratory of Embryonic Stem Cell Research, Hubei University of Medicine, Shiyan, People’s Republic of China
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Anaya Y, Cakmak H, Mata DA, Letourneau J, Zhang L, Lenhart N, Juarez-Hernandez F, Jalalian L, Cedars MI, Rosen M. Triggering with 1,500 IU of human chorionic gonadotropin plus follicle-stimulating hormone compared to a standard human chorionic gonadotropin trigger dose for oocyte competence in in vitro fertilization cycles: a randomized, double-blinded, controlled noninferiority trial. Fertil Steril 2022; 118:266-278. [PMID: 35705380 DOI: 10.1016/j.fertnstert.2022.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 04/29/2022] [Accepted: 05/03/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess if triggering with 1,500 IU of human chorionic gonadotropin (hCG) with 450 IU of follicle-stimulating hormone (FSH) induces noninferior oocyte competence to a standard dose of hCG trigger used in in vitro fertilization (IVF). The alternative trigger will be considered noninferior if it is at least 80% effective in promoting oocyte competence. DESIGN Randomized, double-blinded, controlled noninferiority trial. SETTING Academic infertility practice. PATIENTS Women aged 18-41 undergoing IVF with antral follicle count ≥8, body mass index ≤30 kg/m2, and no history of ≥2 IVF cycles canceled for poor response were enrolled. Participants with a serum estradiol >5,000 pg/mL on the day of trigger were excluded because of high risk of ovarian hyperstimulation syndrome. INTERVENTIONS Participants were randomized to receive an alternative trigger of 1,500 IU of hCG plus 450 IU of FSH or a standard trigger dose of hCG (5,000 or 10,000 IU) for final oocyte maturation. MAIN OUTCOME MEASURES The primary outcome was total competent proportion, defined as the probability of 2 pronuclei from an oocyte retrieved. The alternative trigger will be considered noninferior to the standard trigger if a 1-sided 95% confidence interval (CI) of the relative risk (RR) is not <0.8. Secondary outcomes included oocyte recovery and maturity, intracytoplasmic sperm injection fertilization, embryo quality, pregnancy rates, as well as serum and follicular hormones. Secondary outcomes were compared using a 2-sided superiority test. Outcomes were analyzed by intention-to-treat and per-protocol. RESULTS A total of 105 women undergoing IVF were randomized from May 2015 to June 2018. The probability of the primary outcome was 0.59 with the alternative trigger and 0.65 with the standard trigger, with a RR of 0.91 and a 1-sided 95% CI of 0.83. Noninferiority of the alternative trigger was demonstrated. Live birthrate from all fresh transfers in the alternative trigger group vs. standard trigger was 46.9 vs. 46.4% (RR, 1.01; 95% CI, 0.62-1.62), respectively. Live birthrate per randomized participant was 48.1% in the alternative trigger group vs. 62.7% with the standard trigger (RR, 0.73; 95% CI, 0.48-1.11). No participants had a failed retrieval. CONCLUSION Triggering with 1,500 IU of hCG plus 450 IU of FSH promoted noninferior oocyte competence compared to a standard hCG trigger dose. TRIAL REGISTRATION NCT02310919.
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Affiliation(s)
- Yanett Anaya
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California.
| | - Hakan Cakmak
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California
| | - Douglas A Mata
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joseph Letourneau
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California; Division of Reproductive Endocrinology and Infertility, Utah Center for Reproductive Medicine, University of Utah, Salt Lake City, Utah
| | - Li Zhang
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Nikolaus Lenhart
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California
| | - Flor Juarez-Hernandez
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California
| | - Liza Jalalian
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California
| | - Marcelle I Cedars
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California
| | - Mitchell Rosen
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California
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9
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Leppänen R, Tinkanen H, Huhtala H, Ahinko K. Single-administered GnRH agonist as luteal phase support in insemination cycles: a randomized controlled trial. Gynecol Endocrinol 2022; 38:438-442. [PMID: 35323085 DOI: 10.1080/09513590.2022.2054984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE To find out whether a single-administered GnRH agonist improves the live birth rate in real-life patients undergoing intrauterine insemination (IUI) cycles. STUDY DESIGN A prospective, randomized controlled trial in a public single tertiary center in Tampere University Hospital, Finland. Altogether 251 IUI cycles in 163 patients were randomized to triptorelin and a control group between January 2017 and April 2019. In the triptorelin group, the participants had a single administration of a subcutaneous GnRH agonist triptorelin 0.1 mg at the time of implantation. In the control group, there was no luteal phase support. The primary outcome measure was the live birth rate (LBR). The secondary outcome measures were clinical pregnancy rate (CPR) and miscarriage rate. RESULTS Overall, the live birth rate was lower in the triptorelin group compared to the control group (7.9 vs. 12.1%; p = .297). The clinical pregnancy rates were 12.6 and 13.7%, respectively. There were 2.4% miscarriages in the triptorelin group and no miscarriages in the control group. Ovarian stimulation with letrozole was associated with lower LBR among the triptorelin group, in comparison to the control group (0 vs. 14.7%, p = .020). In contrast, when gonadotrophin was added to the letrozole, LBR was almost doubled compared to the control group (15.9 vs. 8.3%, p = .341). CONCLUSION A single administration of GnRH agonist in the luteal phase does not improve LBR in IUI cycles.
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Affiliation(s)
- Riikka Leppänen
- Department of Obstetrics and Gynaecology, Tampere University Hospital, Tampere, Finland
| | - Helena Tinkanen
- Department of Obstetrics and Gynaecology, Tampere University Hospital, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Katja Ahinko
- Department of Obstetrics and Gynaecology, Tampere University Hospital, Tampere, Finland
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10
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Coughlan C, Vitorino R, Melado L, Digma S, Sibal J, Patel R, Lawrenz B, Fatemi H. Evolution of serum progesterone levels in the very early luteal phase of stimulated IVF/ICSI cycles post hCG trigger: a proof of concept study. J Assist Reprod Genet 2022; 39:1095-1104. [PMID: 35391631 PMCID: PMC9107532 DOI: 10.1007/s10815-022-02474-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 03/19/2022] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Studies have suggested that controlled ovarian hyperstimulation adversely affects endometrial receptivity due to advanced endometrial maturation. This adverse effect is mainly attributed to supraphysiological levels of both estrogen and progesterone identified in stimulated cycles. There is a paucity of published data investigating the very early luteal steroid profile following hCG trigger. AIM OF THE STUDY This prospective, observational study was undertaken to determine the increase in serum progesterone levels after human chorionic gonadotrophin (hCG) trigger in stimulated IVF/ICSI cycles. MATERIALS AND METHODS This proof-of-concept study included 11 patients requiring ovarian stimulation for IVF/ICSI and who planned to avail of pre-implantation genetic screening with embryo vitrification of their biopsied embryos at blastocyst stage. For each study participant, five additional blood samples were drawn at the following specific times in the stimulation cycle, on the morning (10.00-12.00) of the assigned day to induce final oocyte maturation with hCG trigger, immediately prior to administration of hCG for final oocyte maturation, 1 h, 2 h, and 36 h post hCG trigger. A prediction model, the Gompertz curve, was used to determine serum progesterone levels at intervals between the 2 h post hCG trigger sample and the day of oocyte retrieval. RESULTS Statistically significant increases in serum progesterone levels were identified following hCG administration as early as 1 h following trigger (P4 0.57 ng/ml, p < 0.05), 2 h following trigger (P4 0.88 ng/ml, p < 0.001) and on the day of oocyte retrieval (P4 9.68 ng/ml, p < 0.001). According to our prediction model, the Gompertz curve, the projected serum progesterone level at 4 h post trigger would have achieved a level of 1.45 ng/ml, 8 h post trigger of 3.04 ng/ml, and 12 h post trigger of 4.8 ng/ml. The very early and significant increases in serum progesterone following hCG trigger are clearly demonstrated in this study. CONCLUSION The endometrium is undoubtedly exposed to rapidly increasing serum progesterone levels post hCG trigger that would not be identified until much later in natural menstrual cycles. TRIAL REGISTRATION NUMBER This study is registered with clinicaltrials.gov under the identifier NCT04417569.
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Affiliation(s)
- Carol Coughlan
- ART Fertility Clinic Dubai, DMCC-F109B, Red Diamond Building, Al Sarayat Street, Dubai, UAE. .,ART Fertility Clinic Abu Dhabi, Royal Marina Village, Villa B22-23, Abu Dhabi, UAE.
| | - R Vitorino
- ART Fertility Clinic Abu Dhabi, Royal Marina Village, Villa B22-23, Abu Dhabi, UAE
| | - L Melado
- ART Fertility Clinic Abu Dhabi, Royal Marina Village, Villa B22-23, Abu Dhabi, UAE
| | - S Digma
- ART Fertility Clinic Abu Dhabi, Royal Marina Village, Villa B22-23, Abu Dhabi, UAE
| | - J Sibal
- ART Fertility Clinic Abu Dhabi, Royal Marina Village, Villa B22-23, Abu Dhabi, UAE
| | - R Patel
- ART Fertility Clinic Abu Dhabi, Royal Marina Village, Villa B22-23, Abu Dhabi, UAE
| | - B Lawrenz
- ART Fertility Clinic Abu Dhabi, Royal Marina Village, Villa B22-23, Abu Dhabi, UAE.,Women's University Hospital Tuebingen, Calwers tr., 72076, Tuebingen, Germany
| | - H Fatemi
- ART Fertility Clinic Abu Dhabi, Royal Marina Village, Villa B22-23, Abu Dhabi, UAE
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11
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Zhao J, Hao J, Li Y. Individualized luteal phase support after fresh embryo transfer: unanswered questions, a review. Reprod Health 2022; 19:19. [PMID: 35065655 PMCID: PMC8783459 DOI: 10.1186/s12978-021-01320-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 12/23/2021] [Indexed: 12/20/2022] Open
Abstract
Background Luteal phase support (LPS) is an important part of assisted reproductive technology (ART), and adequate LPS is crucial for embryo implantation. At present, a great number of studies have put emphasis on an individualized approach to controlled ovarian stimulation (COS) and endometrium preparation of frozen- thawed embryo transfer (FET); However, not much attention has been devoted to the luteal phase and almost all ART cycles used similar LPS protocol bases on experience. Main body This review aims to concisely summarize individualized LPS protocols in fresh embryo transfer cycles with hCG trigger or GnRH-a trigger. The PubMed and Google Scholar databases were searched using the keywords: (luteal phase support or LPS) AND (assisted reproductive technology or ART or in vitro fertilization or IVF). We performed comprehensive literature searches in the English language describing the luteal phase support after ART, since 1978 and ending in May 2019. Recent studies have shown that many modified LPS programs were used in ART cycle. In the cycle using hCG for final oocyte maturation, the progesterone with or without low dose of hCG may be adequate to maintain pregnancy. In the cycle using GnRH-a for trigger, individualized low dose of hCG administration with or without progesterone was suggested. The optimal timing to start the LPS would be between 24 and 72 h after oocyte retrieval and should last at least until the pregnancy test is positive. Addition of E2 and the routes of progesterone administration bring no beneficial effect on the outcomes after ART. Conclusions Individualized LPS should be applied, according to the treatment protocol, the patients’ specific characteristics, and desires. Luteal phase support (LPS) is an important part of assisted reproductive technology (ART). In the cycle using hCG for final oocyte maturation, the progesterone with or without low dose of hCG may be adequate to maintain pregnancy. In the cycle using GnRH-a for trigger, individualized low dose of hCG administration with or without progesterone was suggested. The optimal timing to start the LPS would be between 24 and 72 h after oocyte retrieval and should last at least until the pregnancy test is positive. Addition of E2 and the routes of progesterone administration bring no beneficial effect on the outcomes after ART. Individualized LPS should be applied, according to the treatment protocol, the patients’ specific characteristics, and desires.
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Affiliation(s)
- Jing Zhao
- Reproductive Medicine Center, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha City, Hunan Province, People's Republic of China.,Clinical Research Center For Women's Reproductive Health In Hunan Province, Hunan, People's Republic of China
| | - Jie Hao
- Reproductive Medicine Center, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha City, Hunan Province, People's Republic of China.,Clinical Research Center For Women's Reproductive Health In Hunan Province, Hunan, People's Republic of China
| | - Yanping Li
- Reproductive Medicine Center, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha City, Hunan Province, People's Republic of China. .,Clinical Research Center For Women's Reproductive Health In Hunan Province, Hunan, People's Republic of China.
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12
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Oral S, Karacan M, Akpak YK, Şişmanoğlu A, Sancaklı Usta C. Live birth rate with double ovarian stimulation is superior to follicular phase ovarian stimulation per started cycle in poor ovarian responders. J Obstet Gynaecol Res 2021; 47:2705-2712. [PMID: 34062624 DOI: 10.1111/jog.14871] [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: 01/09/2021] [Revised: 04/12/2021] [Accepted: 05/16/2021] [Indexed: 11/29/2022]
Abstract
AIM To compare the outcome of double ovarian stimulation (DOS) with follicular phase ovarian stimulation (FPS) per started cycle in poor ovarian responders (PORs). METHODS A total of 204 PORs who underwent ovulation induction for in vitro fertilization, cryopreservation of all embryos available, and frozen embryo transfer cycle were retrospectively analyzed. Of those, 146 received single FPS, and 58 received DOS. All viable embryos were cryopreserved and subsequently transferred within 1-6 months. RESULTS The number of oocytes collected and the number of mature oocytes per started cycle were higher in the DOS group compared to the FPS group (6.0 ± 1.9 vs. 2.8 ± 1.3 and 4.3 ± 1.3 vs. 2.2 ± 1.2, respectively, p = 0.001). Clinical pregnancy rate and live birth rate per started cycle were also significantly higher in the DOS group than the FPS group (41.4% vs. 16.4% and 36.2% vs. 15.1%, respectively, p < 0.001). The cancellation rate of embryo transfer due to no viable embryo was significantly lower in the DOS group (10.3%) than the FPS group (40.4%) (p = 0.001). In the DOS group, numbers of oocytes (3.2 ± 1.2 vs. 2.7 ± 1.1, p = 0.006), MII oocytes (2.6 ± 1.0 vs. 2.1 ± 0.8, p = 0.001), and cryopreserved blastocysts (1.5 ± 0.8 vs. 1.1 ± 0.7, p = 0.002) were significantly higher in the luteal ovarian stimulation compared to follicular ovarian stimulation. CONCLUSIONS Live birth per started cycle with DOS is superior to FPS in PORs. Luteal phase stimulation contributes to improving pregnancy rates in these patients.
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Affiliation(s)
- Serkan Oral
- Department of Obstetrics and Gynaecology, Halic University, Istanbul, Turkey
| | - Meriç Karacan
- Department of Obstetrics and Gynaecology, Yeni Yuzyil University, Istanbul, Turkey
| | - Yaşam K Akpak
- Tepecik Training and Research Hospital, Department of Obstetrics and Gynaecology, University of Health Sciences, Izmir, Turkey
| | - Alper Şişmanoğlu
- Department of Obstetrics and Gynaecology, Altınbas University, Istanbul, Turkey
| | - Ceyda Sancaklı Usta
- Department of Obstetrics and Gynaecology, Balıkesir University, Balıkesir, Turkey
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13
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Racca A, Polyzos NP. DuoStim: are we really comparing follicular phase with luteal phase stimulations? Hum Reprod 2021; 36:1722-1723. [PMID: 33615353 DOI: 10.1093/humrep/deab017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- A Racca
- Department of Obstetrics Gynecology and Reproductive Medicine, Dexeus Mujer, Dexeus University Hospital, 08028 Barcelona, Spain
| | - N P Polyzos
- Department of Obstetrics Gynecology and Reproductive Medicine, Dexeus Mujer, Dexeus University Hospital, 08028 Barcelona, Spain.,Faculty of Medicine and Health Sciences, Ghent University, 9000 Ghent, Belgium
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14
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Hershko Klement A, Orvieto R, Esh Broder E, Frei J, Solnica A, Zandman O, Holzer H, Haas J. How far is too far? Does time interval between GnRH antagonist and GnRH agonist trigger in GnRH antagonist cycles matter? Reprod Biomed Online 2021; 43:233-238. [PMID: 34215488 DOI: 10.1016/j.rbmo.2021.05.004] [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: 03/22/2021] [Revised: 04/28/2021] [Accepted: 05/01/2021] [Indexed: 10/21/2022]
Abstract
RESEARCH QUESTION What is a suitable time interval between the last GnRH antagonist exposure and GnRH agonist (GnRHa) triggering for final follicular maturation? DESIGN A retrospective cohort study including 413 patients undergoing GnRH antagonist cycles in which GnRHa trigger was used, either solely or as a dual trigger. The primary outcome measure was the follicle/mature oocyte ratio. Cycles were analysed according to the time interval between the last GnRH antagonist exposure and the GnRHa triggering: Group 1 included patients with a 12-14 h interval; Group 2: 7-10 h interval; Group 3: 5-6 h interval and Group 4: 2-4 h interval. LH concentration was measured 11-13 h post-GnRHa injection. RESULTS Median LH value was 65 IU/l. There was a weak but significant correlation between basal LH and the LH surge (R2 = 0.137, P < 0.001). Although square root LH values differed significantly between study groups (P < 0.001; higher in Groups 2 and 3), the follicle/mature oocyte ratio was not different across the four antagonist-agonist interval groups and no correlation was detected between the post-trigger LH concentration and the follicle/oocyte ratio (R2 = 0.011). In a model integrating age, day 3 FSH concentration, maximal oestradiol and body mass index along with the study groups, none of these factors was significantly related to the follicle/mature oocyte outcome ratio. Insufficient surge (LH < 15 IU/l) occurred in 14 (3.4%) cases. Rates of insufficient LH surge did not differ significantly between the groups (2.4%, 3.2%, 3.4% and 7.1% in Groups 1 to 4, respectively; P = 0.5). CONCLUSIONS LH concentrations post-GnRHa trigger differ in regard to antagonist-agonist intervals, but the follicle/mature oocyte ratio achieved was not affected.
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Affiliation(s)
- Anat Hershko Klement
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Mt. Scopus Jerusalem, Israel; Faculty of Medicine, The Hebrew University Jerusalem, Israel.
| | - Raoul Orvieto
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hasomer, Israel; The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Efrat Esh Broder
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Mt. Scopus Jerusalem, Israel; Faculty of Medicine, The Hebrew University Jerusalem, Israel
| | - Judith Frei
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hasomer, Israel
| | - Amy Solnica
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Mt. Scopus Jerusalem, Israel; Henrietta Szold School of Nursing, Faculty of Medicine, The Hebrew University Jerusalem, Israel
| | - Orit Zandman
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hasomer, Israel
| | - Hananel Holzer
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Mt. Scopus Jerusalem, Israel; Faculty of Medicine, The Hebrew University Jerusalem, Israel
| | - Jigal Haas
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hasomer, Israel; The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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15
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Maslow BSL, Guarnaccia M, Stefanacci C, Ramirez L, Klein JU. The use of GnRH-agonist trigger for the final maturation of oocytes in normal and low responders undergoing planned oocyte cryopreservation. Hum Reprod 2021; 35:1054-1060. [PMID: 32406915 DOI: 10.1093/humrep/deaa042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 02/07/2020] [Accepted: 02/16/2020] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION Does GnRH-agonist trigger offer similar maturity rate (MR) in low and normal responders compared to high responders in women undergoing planned oocyte cryopreservation, for whom even a small risk of ovarian hyperstimulation syndrome (OHSS) may not be acceptable? SUMMARY ANSWER GnRH-agonist is an appropriate choice for final maturation of oocytes in planned oocyte cryopreservation, regardless of response to stimulation or risk of ovarian hyperstimulation syndrome. WHAT IS KNOWN ALREADY Numerous studies have demonstrated the utility of GnRH-agonist trigger for the prevention of ovarian hyperstimulation in high-responder in vitro fertilization cycles. Limited data exist supporting its use in normal or low responders, or in non-infertile women undergoing planned oocyte cryopreservation. STUDY DESIGN, SIZE, DURATION Retrospective cohort study of 1189 subjects including all planned oocyte cryopreservation cycles performed at a large, single center, oocyte cryopreservation program from April 2016 to December 2018. PARTICIPANTS/MATERIALS, SETTING, METHODS A total of 1680 cycles were included in the study. A total of 57.1% (959/1680) utilized GnRH-agonist for trigger. Demographic and clinical data were collected from the medical record. Maturation rate was calculated for the entire cohort, and by trigger type, using the quotient of Metaphase II (MII) oocytes and retrieved oocytes. A sub-cohort of GnRH-agonist trigger cycles were categorized by peak estradiol (E2) levels and maturation rates compared between groups. Associations were made using Student's t test, ANOVA, Mann-Whitney U and Kruskal-Wallis, where appropriate. A sample size calculation for 90% power with a significance of 5% to detect non-inferiority of <0.05 from a 0.75 maturity rate between subjects with E2 > 3000 pg/mL and E2 < 3000 pg/mL demonstrated the need for at least 116 cycles per group. MAIN RESULTS AND THE ROLE OF CHANCE Mean MR was 0.71 ± 0.19 overall, and 0.73 ± 0.18 in the sub-cohort of GnRH-agonist trigger cycles. A total of 611 cycles (63.7%) had peak E2 < 3000, and 331 (34.5%) had E2 > 3000. No significant difference in maturity rate was noted between cycles with E2 levels >3000 pg/mL and <3000 pg/mL (0.72 ± 0.19 vs. 0.74 ± 0.14, P = 0.18), confirming the non-inferiority of maturity rates with GnRH-agonist triggers in cycles with peak E2 < 3000 pg/mL. While lower mean oocytes retrieved and mean MII oocytes were associated with lower peak E2 levels, maturity rate did not significantly differ amongst E2 level groups. Cycles with E2 < 1000 pg/mL had lower MR irrespective of trigger type. LIMITATIONS, REASONS FOR CAUTION The retrospective nature cannot entirely exclude selection biases, confounding factors or additional variables that could not be accounted for or were not collected by the electronic medical record. Given the nature of planned oocyte cryopreservation, studies of ongoing pregnancy rates and birth outcomes will naturally be delayed. Lastly, the study population was limited to women undergoing planned oocyte cryopreservation; therefore, the results may not be generalizable to women undergoing in vitro fertilization. WIDER IMPLICATIONS OF THE FINDINGS This is the first study specifically comparing the efficacy of GnRH-agonist in patients at lower risk for OHSS to those at high risk, as well the first study evaluating GnRH-agonist's efficacy specifically in planned oocyte cryopreservation cycles. STUDY FUNDING/COMPETING INTEREST(S) Study support provided by departmental funds from the Center for Fertility Research and Education-Extend Fertility Medical Practice. BLM discloses personal fees from Ferring Pharmaceuticals and Merck KgAA, unrelated to the submitted work. C.S., M.G., L.R. and J.K. have nothing to disclose. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- Bat-Sheva L Maslow
- Center for Fertility Research and Education, Extend Fertility, 200 West 57th Street, Suite 1101 New York, NY 10019, USA
| | - Michael Guarnaccia
- Center for Fertility Research and Education, Extend Fertility, 200 West 57th Street, Suite 1101 New York, NY 10019, USA
| | - Cara Stefanacci
- Center for Fertility Research and Education, Extend Fertility, 200 West 57th Street, Suite 1101 New York, NY 10019, USA
| | - Leslie Ramirez
- Center for Fertility Research and Education, Extend Fertility, 200 West 57th Street, Suite 1101 New York, NY 10019, USA
| | - Joshua U Klein
- Center for Fertility Research and Education, Extend Fertility, 200 West 57th Street, Suite 1101 New York, NY 10019, USA
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16
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Humaidan P, Alsbjerg B, Elbaek HO, Povlsen BB, Laursen RJ, Jensen MB, Mikkelsen AT, Thomsen LH, Kol S, Haahr T. The exogenous progesterone-free luteal phase: two pilot randomized controlled trials in IVF patients. Reprod Biomed Online 2021; 42:1108-1118. [PMID: 33931371 DOI: 10.1016/j.rbmo.2021.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 02/22/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Abstract
RESEARCH QUESTION Is the reproductive outcome similar after gonadotrophin-releasing hormone agonist (GnRHa) trigger followed by luteal human chorionic gonadotrophin (HCG) boluses compared with HCG trigger and a standard luteal phase support (LPS)? DESIGN Two open-label pilot randomized controlled trials (RCT) with 250 patients from 2014 to 2019, with a primary outcome of ongoing pregnancy per embryo transfer. Patients with ≤13 follicles on the trigger day were randomized (RCT 1) to: Group A (n = 65): GnRHa trigger followed by a bolus of 1500 IU HCG s.c. on the oocyte retrieval day (ORD) and 1000 IU HCG s.c. 4 days later, and no vaginal LPS; or Group B (n = 65): 6500 IU HCG trigger, followed by a standard vaginal progesterone LPS. Patients with 14-25 follicles on the trigger day were randomized (RCT 2) to Group C (n = 60): GnRHa trigger followed by 1000 IU HCG s.c. on ORD and 500 IU HCG s.c. 4 days later, and no vaginal LPS; or Group D (n = 60): 6500 IU HCG trigger and a standard vaginal LPS. RESULTS In RCT 1, the ongoing pregnancy rate was 44% (22/50) in the GnRHa group versus 46% (25/54) in the HCG trigger group (RR 0.95, 95% CI 0.62-1.45). No ovarian hyperstimulation syndrome (OHSS) was seen in Groups A or B. In RCT 2, the ongoing pregnancy rate was 51% (25/49) in the GnRHa group versus 60% (31/52) in the HCG trigger group (RR 0.86, 95% CI 0.60-1.22). The OHSS rates were 3.3% and 6.7%, respectively. CONCLUSIONS Although a larger-scale study is needed before standard clinical implementation, the present study supports that the exogenous progesterone-free LPS is efficacious, simple and patient-friendly.
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Affiliation(s)
- Peter Humaidan
- The Fertility Clinic, Skive Regional Hospital, Resenvej 25, Skive 7800, Denmark; Faculty of Health, Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, Aarhus 8200, Denmark.
| | - Birgit Alsbjerg
- The Fertility Clinic, Skive Regional Hospital, Resenvej 25, Skive 7800, Denmark; Faculty of Health, Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, Aarhus 8200, Denmark
| | - Helle Olesen Elbaek
- The Fertility Clinic, Skive Regional Hospital, Resenvej 25, Skive 7800, Denmark
| | - Betina Boel Povlsen
- The Fertility Clinic, Skive Regional Hospital, Resenvej 25, Skive 7800, Denmark
| | | | - Mette Brix Jensen
- The Fertility Clinic, Skive Regional Hospital, Resenvej 25, Skive 7800, Denmark
| | | | - Lise Haaber Thomsen
- The Fertility Clinic, Skive Regional Hospital, Resenvej 25, Skive 7800, Denmark
| | - Shahar Kol
- IVF Unit, Elisha Hospital, Yair Kats St 12, Haifa, Israel
| | - Thor Haahr
- The Fertility Clinic, Skive Regional Hospital, Resenvej 25, Skive 7800, Denmark; Faculty of Health, Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, Aarhus 8200, Denmark
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Benmachiche A, Benbouhedja S, Zoghmar A, Al Humaidan PSH. The impact of preovulatory versus midluteal serum progesterone level on live birth rates during fresh embryo transfer. PLoS One 2021; 16:e0246440. [PMID: 33571260 PMCID: PMC7877612 DOI: 10.1371/journal.pone.0246440] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/18/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Conflicting evidence still prevails concerning the effect of preovulatory elevated progesterone (EP4) on reproductive outcomes in fresh embryo transfer (ET). However, few studies have analyzed the effect of EP4 on the likelihood of pregnancy using multivariate regression approach. The potential confounding factors tested in these studies were limited to either patient's characteristics or to stimulation related parameters. Yet, several studies have shown that postovulatory parameters such as midluteal progesterone (P4) level may be considered as a proxy variable of endometrial receptivity as well. OBJECTIVE The aim of the present study was to estimate the independent effect of preovulatory P4 effect, if any, on the probability of live birth (LB) by considering the midluteal endocrine profile when controlling for the potential confounding factors. METHODS This is a secondary data analysis of a cohort of fresh IVF/ICSI cycles triggered with GnRH agonist (n = 328) performed in a single IVF center during the period 2014-2016. Patients contributed only one cycle and were stratified into four groups according to preovulatory P4 quartiles. We assessed the association between preovulatory P4 and the odds of LB calculated by logistic regression analysis after controlling for the most clinically relevant confounders. The primary outcome measure: Live birth rates (LBR). RESULTS Both preovulatory and midluteal P4 were significantly correlated with the ovarian response. Logistic regression analysis showed that preovulatory serum P4 did not have a significant impact on LBR. In contrast, midluteal serum P4 level was an important independent factor associated with LBR. The optimal chance of LBR was achieved with midluteal serum P4 levels of 41-60 ng/ml, [OR: 2.73 (1.29-5.78); p< 0.008]. CONCLUSION The multivariate analysis suggests that the midluteal P4 level seems to impact LBR more than the preovulatory P4 level in women undergoing IVF treatment followed by fresh ET.
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Affiliation(s)
| | | | - Abdelali Zoghmar
- Center for Reproductive Medicine, Ibn-rochd, Constantine, Algeria
| | - Peter Samir Hesjaer Al Humaidan
- The Fertility Clinic, Skive Region Hospital, Skive, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus C, Denmark
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Gibt es optimale Serumprogesteronwerte in In-vitro-Fertilisations- und Kryozyklen? GYNAKOLOGISCHE ENDOKRINOLOGIE 2021. [DOI: 10.1007/s10304-020-00366-3] [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]
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19
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Tsakiridis I, Najdecki R, Tatsi P, Timotheou E, Kalinderi K, Michos G, Virgiliou A, Yarali H, Athanasiadis A, Papanikolaou EG. Evaluation of the safety and efficacy of corifollitropin alfa combined with GnRH agonist triggering in oocyte donation cycles. A prospective longitudinal study. JBRA Assist Reprod 2020; 24:436-441. [PMID: 32489086 PMCID: PMC7558885 DOI: 10.5935/1518-0557.20200033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective: In order to help make the dream of parenthood come true for oocyte acceptors, it is essential that the procedure is not dangerous or unpleasant for oocyte donors. The aim of this study was to identify differences in safety, efficacy and patient acceptability between a traditional stimulation antagonist protocol with recombinant-FSH (rFSH) with hCG-triggering, compared with an innovative antagonist protocol with corifollitropin alfa (Elonva®) plus GnRH agonist triggering in oocyte donors. Methods: A prospective longitudinal study was conducted at an in vitro fertilization center in Greece. The same eighty donors underwent two consecutive antagonist stimulation schemes. Primary outcomes were patient satisfaction (scored by a questionnaire) and delivery rate per donor. Secondary outcomes were mean number of cumulus-oocyte-complexes, metaphase II (MII) oocytes and ovarian hyperstimulation syndrome (OHSS) rate. Results: Donors reported better adherence and less discomfort with the corifollitropin alpha + GnRH agonist-triggering protocol (p<0.001). No significant differences were identified in the clinical pregnancy rate per donor (p=0.13), the delivery rates, the number of oocytes (p=0.35), the number of MII oocytes (p=0.50) and the number of transferred embryos, between the two protocols. However, the luteal phase duration was significantly shorter (p<0.001) in the corifollitropin alpha + GnRH agonist-triggering protocol. Moreover, three cases of moderate OHSS (3.75%) were identified after hCG triggering, whereas no case of OHSS occurred after GnRH agonist ovulation induction (p=0.25). Conclusion: The use of corifollitropin alpha combined with a GnRH agonist for triggering is a safe, effective and acceptable protocol for oocyte donors.
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Affiliation(s)
- Ioannis Tsakiridis
- 3rd Department Ob-Gyn, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Robert Najdecki
- Assisting Nature, Center of Reproduction & Genetics, Thessaloniki, Greece
| | - Petroula Tatsi
- Assisting Nature, Center of Reproduction & Genetics, Thessaloniki, Greece
| | - Evi Timotheou
- Assisting Nature, Center of Reproduction & Genetics, Thessaloniki, Greece
| | - Kallirhoe Kalinderi
- 3rd Department Ob-Gyn, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgios Michos
- 3rd Department Ob-Gyn, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Andriana Virgiliou
- 3rd Department Ob-Gyn, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | | | - Evangelos G Papanikolaou
- 3rd Department Ob-Gyn, Aristotle University of Thessaloniki, Thessaloniki, Greece.,Assisting Nature, Center of Reproduction & Genetics, Thessaloniki, Greece
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Cimadomo D, Vaiarelli A, Colamaria S, Trabucco E, Alviggi C, Venturella R, Alviggi E, Carmelo R, Rienzi L, Ubaldi FM. Luteal phase anovulatory follicles result in the production of competent oocytes: intra-patient paired case-control study comparing follicular versus luteal phase stimulations in the same ovarian cycle. Hum Reprod 2020; 33:1442-1448. [PMID: 29912374 PMCID: PMC6070116 DOI: 10.1093/humrep/dey217] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 04/19/2018] [Accepted: 05/25/2018] [Indexed: 11/12/2022] Open
Abstract
STUDY QUESTION Are the mean numbers of blastocysts obtained from sibling cohorts of oocytes recruited after follicular phase and luteal phase stimulations (FPS and LPS) in the same ovarian cycle similar? SUMMARY ANSWER The cohorts of oocytes obtained after LPS are larger than their paired-FPS-derived cohorts and show a comparable competence, thus resulting in a larger mean number of blastocysts. WHAT IS KNOWN ALREADY Three theories of follicle recruitment have been postulated to date: (i) the ‘continuous recruitment’ theory, (ii) the ‘single recruitment episode’ theory and (iii) the ‘wave’ theory. Yet, a clear characterization of this crucial biological process for human reproduction is missing. Recent advances implemented in in vitro fertilization (IVF), such as blastocyst culture, aneuploidy testing and vitrification, have encouraged clinicians to maximize the exploitation of the ovarian reserve through tailored stimulation protocols, which is crucial especially for poor prognosis patients aiming to conceive after IVF. LPS has been already successfully adopted to treat poor prognosis or oncological patients through Duostim, LPS-only or random-start ovarian stimulation approaches. Nevertheless, little, and mainly retrospective, evidence has been produced to support the safety of LPS in general. Feasibility of the LPS approach would severely question the classic ‘single recruitment episode’ theory of follicular development. STUDY DESIGN, SIZE, DURATION This case-control study was conducted with paired follicular phase- and luteal phase-derived cohorts of oocytes collected after stimulations in the same ovarian cycle (DuoStim) at two private IVF clinics between October 2015 and December 2017. PARTICIPANTS/MATERIALS, SETTING, METHODS The study included 188 poor prognosis patients undergoing DuoStim with preimplantation genetic testing for aneuploidies (PGT-A). FPS and LPS were performed with the same daily dose of recombinant-gonadotrophins in an antagonist protocol. Blastocyst culture, trophectoderm biopsy, vitrification and frozen-warmed euploid single blastocyst transfers were performed. The primary outcome was the mean number of blastocysts obtained per oocyte retrieval from paired-FPS- and LPS-derived cohorts (required sample size = 165 patients; power = 90%). Mean blastulation and euploidy rates were monitored, along with the number of oocytes, euploid blastocysts and clinical outcomes. MAIN RESULTS AND THE ROLE OF CHANCE Significantly fewer blastocysts were obtained after FPS than LPS (1.2 ± 1.1 vs. 1.6 ± 1.6, P < 0.01), due to fewer oocytes collected (3.6 ± 2.1 vs. 4.3 ± 2.8, P < 0.01) and a similar mean blastocyst rates per retrieval (33.1% ± 30.3% vs. 37.4% ± 30.8%, P = NS). The number of oocytes collected were correlated (R = 0.5, P < 0.01), while the blastocyst rates were uncorrelated among paired-FPS- and LPS-derived cohorts. Overall, a significantly lower chance of producing blastocyst(s) was reported after FPS than after LPS: 67.6% (n = 127/188, 95%CI: 60.3–74.1) vs. 77.1% (n = 145/188, 95%CI: 70.3–82.8; P = 0.05). The mean euploidy rates per retrieval were similar between FPS- and LPS-derived cohorts of oocytes (13.6% ± 22.8% vs. 16.3% ± 23.4%, P = NS). Therefore, on average fewer euploid blastocysts (0.5 ± 0.8 vs. 0.7 ± 1.0, P = 0.02) resulted from FPS. Similar ongoing-pregnancy/delivery rates were reported, to date, after FPS- and LPS-derived euploid single blastocyst transfers: 42.4% (n = 28/66, 95%CI: 30.5–55.2) vs. 53.8% (n = 35/65, 95%CI: 41.1–66.1; P = NS). LIMITATIONS, REASONS FOR CAUTION More studies need to be conducted in the future to confirm the safety of LPS, especially in terms of ovarian and follicular environment, as well as the clinical, peri-natal and post-natal outcomes. Here, we showed preliminary data suggesting a similar ongoing implantation/delivery rate (>22 weeks) between FPS- and LPS-derived euploid blastocysts, that need to be extended in the future, to populations other than poor prognosis patients and using approaches other than DuoStim together with a constant monitoring of the related peri-natal and post-natal outcomes. WIDER IMPLICATIONS OF THE FINDINGS These data, from a paired study design, highlight that LPS-derived oocytes are as competent as FPS-derived oocytes, thereby adding some evidence to support the use of LPS for poor prognosis and oncological patients and to question the ‘single recruitment episode’ theory of follicle recruitment. These findings also encourage additional studies of the basics of folliculogenesis, with direct clinical implications for the management of ovarian stimulation in IVF. TRIAL REGISTRATION None. STUDY FUNDING/COMPETING INTEREST(S) No external funds were used for this study and there are no conflicts of interest.
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Affiliation(s)
- Danilo Cimadomo
- Clinica Valle Giulia, G.EN.E.R.A. Centers for Reproductive Medicine, Rome, Italy
| | - Alberto Vaiarelli
- Clinica Valle Giulia, G.EN.E.R.A. Centers for Reproductive Medicine, Rome, Italy
| | - Silvia Colamaria
- Clinica Valle Giulia, G.EN.E.R.A. Centers for Reproductive Medicine, Rome, Italy
| | - Elisabetta Trabucco
- Clinica Ruesch, G.EN.E.R.A. Centers for Reproductive Medicine, Naples, Italy
| | - Carlo Alviggi
- Dipartimento di Neuroscienze, Scienze riproduttive ed Odontostomatologiche, Università degli Studi di Napoli 'Federico II', Naples, Italy.,Istituto per l'Endocrinologia e l'Oncologia Sperimentale, Consiglio Nazionale delle Ricerche, Naples, Italy
| | - Roberta Venturella
- Dipartimento di medicina clinica e sperimentale, Universita' degli Studi Magna Græcia di Catanzaro, Catanzaro, Italy
| | - Erminia Alviggi
- Clinica Ruesch, G.EN.E.R.A. Centers for Reproductive Medicine, Naples, Italy
| | - Ramona Carmelo
- Clinica Ruesch, G.EN.E.R.A. Centers for Reproductive Medicine, Naples, Italy
| | - Laura Rienzi
- Clinica Valle Giulia, G.EN.E.R.A. Centers for Reproductive Medicine, Rome, Italy.,Clinica Ruesch, G.EN.E.R.A. Centers for Reproductive Medicine, Naples, Italy
| | - Filippo Maria Ubaldi
- Clinica Valle Giulia, G.EN.E.R.A. Centers for Reproductive Medicine, Rome, Italy.,Clinica Ruesch, G.EN.E.R.A. Centers for Reproductive Medicine, Naples, Italy
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Tokgoz VY, Sipahi M, Aydin Y, Tekin AB. Does multifollicular development and number of intermediate follicles contribute to the effect of luteal phase support with vaginal progesterone gel in intrauterine insemination cycles? Gynecol Endocrinol 2020; 36:72-76. [PMID: 31237153 DOI: 10.1080/09513590.2019.1631277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Luteal phase deficiency as a result of multifollicular development which produces supraphysiological progesterone and estradiol levels and benefit of luteal phase support have been proven in assisted reproductive technique (ART) treatment. But, there were some controversial results in intrauterine insemination (IUI) cycles whether luteal phase support (LPS) with progesterone have an impact on pregnancy outcome. To assess the efficacy of vaginal progesterone gel in the gonadotropin-induced IUI cycles, this retrospective data analysis compared the luteal phase support and control group in terms of clinical pregnancy (CPR) and live birth rates (LBR). In subgroup analysis, multifollicular and monofollicular growth were analyzed separately. In total, after exclusion criteria, 380 IUI cycles were analyzed, cycles were grouped as LPS(+) and LPS(-) with 190 and 190 cycles, respectively. CPR and LBR were comparable between groups (11.6% vs. 10.5, p = .74 and 8.9% vs. 8.4%, p = .75 respectively). Although multifollicular growth demonstrated higher pregnancy outcomes than monofollicular growth, intermediate follicles (14-16 mm) had a positive impact on pregnancy outcome in monofollicular growth like multifollicular subgroup. We found no difference in CPR and LBR according to the luteal phase vaginal progesterone gel. Nevertheless, multifollicular cycles and also monofollicular growth cycles with two and more intermediate follicles may have benefit LPS in gonadotropin-induced IUI cycles.
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Affiliation(s)
- Vehbi Yavuz Tokgoz
- Obstetrics and Gynecology, Eskisehir Osmangazi Universitesi, Eskisehir, Turkey
| | - Mehmet Sipahi
- Obstetrics and Gynecology, Giresun Universitesi, Giresun, Turkey
| | - Yunus Aydin
- Obstetrics and Gynecology, Denizli Ozel Saglik Hastanesi, Denizli, Turkey
| | - Ahmet Basar Tekin
- Obtetrics and Gynecology, Eskisehir Osmangazi Universitesi, Eskisehir, Turkey
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Vaiarelli A, Cimadomo D, Conforti A, Schimberni M, Giuliani M, D'Alessandro P, Colamaria S, Alviggi C, Rienzi L, Ubaldi FM. Luteal phase after conventional stimulation in the same ovarian cycle might improve the management of poor responder patients fulfilling the Bologna criteria: a case series. Fertil Steril 2019; 113:121-130. [PMID: 31837743 DOI: 10.1016/j.fertnstert.2019.09.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 09/04/2019] [Accepted: 09/09/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To assess the clinical contribution of luteal-phase stimulation (LPS) to follicular-phase stimulation (FPS) in a single ovarian cycle (DuoStim) for poor responder patients fulfilling the Bologna criteria. DESIGN Observational study (years 2015-2017) including women satisfying ≥2 of the following characteristics: maternal age ≥40 years and/or ≤3 oocytes retrieved after previous conventional stimulation and/or reduced ovarian reserve (i.e., antral follicle count <7 follicles or antimüllerian hormone <1.1 ng/mL). The LPS was started regardless of the outcome of the FPS. SETTING Private in vitro fertilization center. PATIENT(S) A total of 100 of 297 patients fulfilling the Bologna criteria chose to undergo DuoStim. INTERVENTION(S) The FPS and LPS with the same antagonist protocol and agonist trigger, intracytoplasmic sperm injection with ejaculated sperm, preimplantation genetic testing for aneuploidies, and vitrified-warmed euploid single blastocyst transfer. MAIN OUTCOME MEASURE(S) The contribution of LPS to the cumulative live birth rate (CLBR) per intention-to-treat (ITT). RESULT(S) Patients (100) underwent FPS (maternal age, 42.1 ± 1.4 y; previous in vitro fertilization cycles with ≤3 collected oocytes, 0.7 ± 0.9; antral follicle count, 3.8 ± 1.2 follicles; and antimüllerian hormone, 0.56 ± 0.3 ng/mL). Ninety-one patients completed DuoStim. All patients were included in the analysis. More oocytes were obtained after LPS with similar developmental and chromosomal competence as paired FPS-derived ones. The CLBR per ITT increased from 7% after FPS to 15% after DuoStim. Conversely, the CLBR per ITT among the 197 patients that chose a conventional controlled ovarian stimulation strategy was 8%, as only 17 patients who were not pregnant returned for a second stimulation after the first attempt (drop-out rate, 81%). CONCLUSION(S) The LPS-derived oocytes increased the CLBR per ITT in a single ovarian cycle in patients fulfilling the Bologna criteria. The DuoStim strategy is promising to manage this thorny population of patients, especially to avoid discontinuation after a first failed attempt.
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Affiliation(s)
- Alberto Vaiarelli
- Clinica Valle Giulia, G.EN.E.R.A., Centers for Reproductive Medicine, BioRoma, Rome, Rome, Italy.
| | - Danilo Cimadomo
- Clinica Valle Giulia, G.EN.E.R.A., Centers for Reproductive Medicine, BioRoma, Rome, Rome, Italy
| | - Alessandro Conforti
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples, Federico II, Naples, Italy
| | | | - Maddalena Giuliani
- Clinica Valle Giulia, G.EN.E.R.A., Centers for Reproductive Medicine, BioRoma, Rome, Rome, Italy
| | - Pietro D'Alessandro
- Clinica Ruesch, G.EN.E.R.A. Centers for Reproductive Medicine, Naples, Italy
| | - Silvia Colamaria
- Clinica Valle Giulia, G.EN.E.R.A., Centers for Reproductive Medicine, BioRoma, Rome, Rome, Italy
| | - Carlo Alviggi
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples, Federico II, Naples, Italy
| | - Laura Rienzi
- Clinica Valle Giulia, G.EN.E.R.A., Centers for Reproductive Medicine, BioRoma, Rome, Rome, Italy
| | - Filippo Maria Ubaldi
- Clinica Valle Giulia, G.EN.E.R.A., Centers for Reproductive Medicine, BioRoma, Rome, Rome, Italy
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Gaafar S, El-Gezary D, El Maghraby HA. Early onset of cabergoline therapy for prophylaxis from ovarian hyperstimulation syndrome (OHSS): A potentially safer and more effective protocol. Reprod Biol 2019; 19:145-148. [PMID: 31133458 DOI: 10.1016/j.repbio.2019.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/20/2019] [Accepted: 03/28/2019] [Indexed: 01/11/2023]
Abstract
Vascular endothelial growth factor (VEGF) is the most important angiogenic mediator in ovarian hyperstimulation syndrome OHSS. Studies proved that cabergoline administration blocks the increase in vascular permeability via dephosphorylation of VEGF receptors and hence can be used as prophylactic agent against OHSS. This study aimed at evaluating the effectiveness of early administration of cabergoline in the prevention of OHSS in high risk cases prepared for ICSI. This case series study was conducted on 126 high risk patients prepared for ICSI using the fixed antagonist protocol. High risk patients were defined as having more than 20 follicles >12 mm in diameter, and/or E2 more than 3000 pg/ml when the size of the leading follicle is more than 15 mm. When the size of the leading follicle reached 15 mm, cabergoline was administered (0.5 mg/day) for 8 days. Patients were followed up clinically, ultrasonographically and hematologically. The final E2 was 6099.5 ± 2730 and the mean number of retrieved oocytes was 19.7 ± 7.8. The clinical pregnancy rate was 62/126 (49.2%). There were no significant changes (p > 0.05) comparing hematological parameters, renal function tests and liver function tests between the day of HCG and the day of blastocyst transfer. The incidence of severe OHSS in this group was 1/126 (0.9%), while moderate OHSS was 12 (9.5%) and there were no cases of critical OHSS. We concluded that early administration of cabergoline is a safe and potentially more effective approach for prophylaxis against OHSS in high risk cases.
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Affiliation(s)
- Sherif Gaafar
- Department of Obstetrics, Gynecology and Reproductive Medicine, El Shatby University Hospital, Alexandria University, Egypt.
| | - Dalal El-Gezary
- Clinical Pathology Department, Faculty of Medicine, Alexandria University, Egypt.
| | - Hassan A El Maghraby
- Department of Obstetrics, Gynecology and Reproductive Medicine, El Shatby University Hospital, Alexandria University, Egypt.
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Harrison D, Buskmiller C, Chireau M, Ruppersberger LA, Yeung PP. Systematic Review of Ovarian Activity and Potential for Embryo Formation and Loss during the Use of Hormonal Contraception. LINACRE QUARTERLY 2018; 85:453-469. [PMID: 32431378 DOI: 10.1177/0024363918815611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this review was to determine whether there is evidence that ovulation can occur in women using hormonal contraceptives and whether these drugs might inhibit implantation. We performed a systematic review of the published English-language literature from 1990 to the present which included studies on the hormonal milieu following egg release in women using any hormonal contraceptive method. High circulating estrogens and progestins in the follicular phase appear to induce dysfunctional ovulation, where follicular rupture occurs but is followed by low or absent corpus luteum production of progesterone. Hoogland scoring of ovulatory activity may inadvertently obscure the reality of ovum release by limiting the term "ovulation" to those instances where follicular rupture is followed by production of a threshold level of luteal progesterone, sufficient to sustain fertilization, implantation, and the end point of a positive β-human chorionic gonadotropin. However, follicular ruptures and egg release with subsequent low progesterone output have been documented in women using hormonal contraception. In the absence of specific ovulation and fertilization markers, follicular rupture should be considered the best marker for egg release and potential fertilization. Women using hormonal contraceptives may produce more eggs than previously described by established criteria; moreover, suboptimal luteal progesterone production may be more likely than previously acknowledged, which may contribute to embryo loss. This information should be included in informed consent for women who are considering the use of hormonal contraception. Summary For this study, the authors looked at English-language research articles that focused on how hormonal birth control, such as the birth control pill, may affect very early human embryos. The authors found that abnormal ovulation, or release of an egg followed by abnormal hormone levels, may often occur in women using hormonal birth control. This may increase the number of very early human embryos who are lost before a pregnancy test becomes positive. For women who are thinking about using hormonal birth control, this is important information to consider.
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Affiliation(s)
- Donna Harrison
- American Association of Pro-Life Obstetricians and Gynecologists, Eau Claire, MI, USA
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Abbara A, Clarke SA, Dhillo WS. Novel Concepts for Inducing Final Oocyte Maturation in In Vitro Fertilization Treatment. Endocr Rev 2018; 39:593-628. [PMID: 29982525 PMCID: PMC6173475 DOI: 10.1210/er.2017-00236] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 06/27/2018] [Indexed: 01/20/2023]
Abstract
Infertility affects one in six of the population and increasingly couples require treatment with assisted reproductive techniques. In vitro fertilization (IVF) treatment is most commonly conducted using exogenous FSH to induce follicular growth and human chorionic gonadotropin (hCG) to induce final oocyte maturation. However, hCG may cause the potentially life-threatening iatrogenic complication "ovarian hyperstimulation syndrome" (OHSS), which can cause considerable morbidity and, rarely, even mortality in otherwise healthy women. The use of GnRH agonists (GnRHas) has been pioneered during the last two decades to provide a safer option to induce final oocyte maturation. More recently, the neuropeptide kisspeptin, a hypothalamic regulator of GnRH release, has been investigated as a novel inductor of oocyte maturation. The hormonal stimulus used to induce oocyte maturation has a major impact on the success (retrieval of oocytes and chance of implantation) and safety (risk of OHSS) of IVF treatment. This review aims to appraise experimental and clinical data of hormonal approaches used to induce final oocyte maturation by hCG, GnRHa, both GnRHa and hCG administered in combination, recombinant LH, or kisspeptin. We also examine evidence for the timing of administration of the inductor of final oocyte maturation in relationship to parameters of follicular growth and the subsequent interval to oocyte retrieval. In summary, we review data on the efficacy and safety of the major hormonal approaches used to induce final oocyte maturation in clinical practice, as well as some novel approaches that may offer fresh alternatives in future.
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Affiliation(s)
- Ali Abbara
- Department of Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Sophie A Clarke
- Department of Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Waljit S Dhillo
- Department of Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
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Vaiarelli A, Cimadomo D, Trabucco E, Vallefuoco R, Buffo L, Dusi L, Fiorini F, Barnocchi N, Bulletti FM, Rienzi L, Ubaldi FM. Double Stimulation in the Same Ovarian Cycle (DuoStim) to Maximize the Number of Oocytes Retrieved From Poor Prognosis Patients: A Multicenter Experience and SWOT Analysis. Front Endocrinol (Lausanne) 2018; 9:317. [PMID: 29963011 PMCID: PMC6010525 DOI: 10.3389/fendo.2018.00317] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 05/28/2018] [Indexed: 01/15/2023] Open
Abstract
A panel of experts known as the POSEIDON group has recently redefined the spectrum of poor responder patients and introduced the concept of suboptimal response. Since an ideal management for these patients is still missing, they highlighted the importance of tailoring the ovarian stimulation based on the chance of each woman to obtain an euploid blastocyst. Interestingly, a novel pattern of follicle recruitment has been defined: multiple waves may arise during a single ovarian cycle. This evidence opened important clinical implications for the treatment of poor responders. For instance, double stimulation in the follicular (FPS) and luteal phase (LPS) of the same ovarian cycle (DuoStim) is an intriguing option to perform two oocyte retrievals in the shortest possible time. Here, we reported our 2-year experience of DuoStim application in four private IVF centers. To date, 310 poor prognosis patients completed a DuoStim protocol and underwent IVF with blastocyst-stage preimplantation-genetic-testing. LPS resulted into a higher mean number of oocytes collected than FPS; however, their competence (i.e., fertilization, blastocyst, euploidy rates, and clinical outcomes after euploid single-embryo-transfer) was comparable. Importantly, the rate of patients obtaining at least one euploid blastocyst increased from 42.3% (n = 131/310) after FPS to 65.5% (n = 203/310) with the contribution of LPS. A summary of the putative advantages and disadvantages of DuoStim was reported here through a Strengths-Weaknesses-Opportunities-Threats analysis. The strengths of this approach make it very promising. However, more studies are needed in the future to limit its weaknesses, shed light on its putative threats, and realize its opportunities.
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Affiliation(s)
- Alberto Vaiarelli
- Clinica Valle Giulia, G.en.e.r.a. Centers for Reproductive Medicine, Rome, Italy
| | - Danilo Cimadomo
- Clinica Valle Giulia, G.en.e.r.a. Centers for Reproductive Medicine, Rome, Italy
| | - Elisabetta Trabucco
- Clinica Ruesch, G.en.e.r.a. Centers for Reproductive Medicine, Naples, Italy
| | - Roberta Vallefuoco
- Clinica Ruesch, G.en.e.r.a. Centers for Reproductive Medicine, Naples, Italy
| | - Laura Buffo
- G.en.e.r.a. Veneto, G.en.e.r.a. Centers for Reproductive Medicine, Marostica, Italy
| | - Ludovica Dusi
- G.en.e.r.a. Veneto, G.en.e.r.a. Centers for Reproductive Medicine, Marostica, Italy
| | - Fabrizio Fiorini
- G.en.e.r.a. Umbria, G.en.e.r.a. Centers for Reproductive Medicine, Umbertide, Italy
| | - Nicoletta Barnocchi
- G.en.e.r.a. Umbria, G.en.e.r.a. Centers for Reproductive Medicine, Umbertide, Italy
| | | | - Laura Rienzi
- Clinica Valle Giulia, G.en.e.r.a. Centers for Reproductive Medicine, Rome, Italy
- Clinica Ruesch, G.en.e.r.a. Centers for Reproductive Medicine, Naples, Italy
- G.en.e.r.a. Veneto, G.en.e.r.a. Centers for Reproductive Medicine, Marostica, Italy
- G.en.e.r.a. Umbria, G.en.e.r.a. Centers for Reproductive Medicine, Umbertide, Italy
| | - Filippo Maria Ubaldi
- Clinica Valle Giulia, G.en.e.r.a. Centers for Reproductive Medicine, Rome, Italy
- Clinica Ruesch, G.en.e.r.a. Centers for Reproductive Medicine, Naples, Italy
- G.en.e.r.a. Veneto, G.en.e.r.a. Centers for Reproductive Medicine, Marostica, Italy
- G.en.e.r.a. Umbria, G.en.e.r.a. Centers for Reproductive Medicine, Umbertide, Italy
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Lawrenz B, Samir S, Melado L, Ruiz F, Fatemi HM. Luteal phase serum progesterone levels after GnRH-agonist trigger - how low is still high enough for an ongoing pregnancy? Gynecol Endocrinol 2018; 34:195-198. [PMID: 29037085 DOI: 10.1080/09513590.2017.1391204] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
In the past years, individualization of assisted reproductive technique (ART)-treatment is increasingly common to customize the treatment protocol to the patient's specific conditions. The use of GnRH-agonist for final oocyte maturation in a gonadotropin-releasing hormone (GnRH)-antagonist protocol is the best approach to reduce the risk for ovarian hyperstimulation in high responder patients. However, due to severe luteolysis, the reproductive outcome with this approach in combination with the use of vaginal progesterone as luteal phase support, was poor. Cycle segmentation as alternative to a fresh transfer requires embryo freezing which might not be applicable to all patients due to various reasons. The concept of luteal coasting monitors the progesterone-level closely and human chorionic gonadotropin (hCG) for rescue of the corpora lutea is administered when the progesterone-level drops below a certain threshold. However, the lower range of progesterone levels in the early luteal phase after GnRH-agonist trigger, which is compatible with achieving and maintaining a pregnancy, is unknown. This case-series demonstrates, that ongoing pregnancies can be achieved even with a progesterone-level below 15 ng/ml in the early luteal phase with the timely administration of an hCG-rescue bolus. With the concept of luteal coasting, individualization of the luteal phase support according to the patient's specific luteolysis pattern is possible.
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Affiliation(s)
- B Lawrenz
- a IVF-Department, IVI Middle East Fertility Center , Abu Dhabi , UAE
- b Obstetrical Department, Women´s university hospital Tuebingen , Tuebingen , Germany
| | - S Samir
- a IVF-Department, IVI Middle East Fertility Center , Abu Dhabi , UAE
| | - L Melado
- a IVF-Department, IVI Middle East Fertility Center , Abu Dhabi , UAE
| | - F Ruiz
- a IVF-Department, IVI Middle East Fertility Center , Abu Dhabi , UAE
| | - H M Fatemi
- a IVF-Department, IVI Middle East Fertility Center , Abu Dhabi , UAE
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Vanetik S, Segal L, Breizman T, Kol S. Day two post retrieval 1500 IUI hCG bolus, progesterone-free luteal support post GnRH agonist trigger - a proof of concept study. Gynecol Endocrinol 2018; 34:132-135. [PMID: 28933569 DOI: 10.1080/09513590.2017.1379496] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Small dose of hCG (1500 IU) on the day of oocyte retrieval, followed by daily progesterone administration, is currently the preferred way to secure adequate luteal support following GnRH agonist trigger. In the current proof-of-concept study, we explored the possibility that a bolus of 1500 IU hCG, given two days after oocyte retrieval, may be sufficient to sustain adequate luteal support without additional progesterone treatment. From February 2015 to August 2016, we obtained 44 pregnancies following GnRHa trigger followed by day 2 hCG (1500 IU) support only (study group). Data from these 44 cycles were compared with the latest 44 pregnancies obtained following hCG (6500 IU) trigger followed by conventional progesterone luteal documented (control group). Mean progesterone levels (14 days postoocyte retrieval) in the study and control groups were 197 nmol/l and 173 nmol/l, respectively (NS). Mean E2 levels (14 days post oocyte retrieval) in the study group was 6937 pmol/l, significantly higher (p < .001) than in the control group (3.276 pmol/l). We conclude that bolus of 1500 IU hCG, administered 2 days after retrieval, can provide excellent support, without the need to further supplement with progesterone.
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Affiliation(s)
- Sharon Vanetik
- a Ruth and Bruce Rappaport Faculty of medicine , Technion - Israel Institute of Technology , Haifa , Israel
| | - Linoy Segal
- a Ruth and Bruce Rappaport Faculty of medicine , Technion - Israel Institute of Technology , Haifa , Israel
| | - Tatiana Breizman
- b Department of Obstetrics and Gynecology , IVF Unit , Haifa , Israel
| | - Shahar Kol
- a Ruth and Bruce Rappaport Faculty of medicine , Technion - Israel Institute of Technology , Haifa , Israel
- b Department of Obstetrics and Gynecology , IVF Unit , Haifa , Israel
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GnRHa trigger and luteal coasting: a new approach for the ovarian hyperstimulation syndrome high-risk patient? Reprod Biomed Online 2018; 36:75-77. [DOI: 10.1016/j.rbmo.2017.09.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 07/28/2017] [Accepted: 09/14/2017] [Indexed: 11/21/2022]
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Lawrenz B, Samir S, Garrido N, Melado L, Engelmann N, Fatemi HM. Luteal Coasting and Individualization of Human Chorionic Gonadotropin Dose after Gonadotropin-Releasing Hormone Agonist Triggering for Final Oocyte Maturation-A Retrospective Proof-of-Concept Study. Front Endocrinol (Lausanne) 2018; 9:33. [PMID: 29497400 PMCID: PMC5818401 DOI: 10.3389/fendo.2018.00033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Accepted: 01/24/2018] [Indexed: 11/13/2022] Open
Abstract
Ovarian stimulation in a gonadotropin-releasing hormone (GnRH) antagonist protocol with the use of GnRH agonist for final oocyte maturation is the state-of-the-art treatment in patients with an expected or known high response to avoid or at least reduce significantly the risk for development of ovarian hyperstimulation syndrome (OHSS). Due to a shortened LH surge after administration of GnRH agonist in most patients, the luteal phase will be characterized by luteolysis and luteal phase insufficiency. Maintaining a sufficient luteal phase is crucial for achievement of a pregnancy; however, the optimal approach is still under debate. Administration of human chorionic gonadotropin (hCG) within 72 h rescues the corpora lutea function; however, the so far often used 1,500 IU still bear the risk for development of OHSS. The recently introduced concept of "luteal coasting" individualizes the luteal phase support by monitoring the progesterone concentrations and administering a rescue dosage of hCG when progesterone concentrations drop significantly. This retrospective proof-of-concept study explored the correlation between hCG dosages ranging from 375 up to 1,500 IU and the progesterone levels in the early and mid-luteal phases as well as the likelihood of pregnancy, both early and ongoing. The chance of pregnancy is highest with progesterone level ≥13 ng/ml at 48 h postoocyte retrieval. Among the small sample size of 52 women studied, it appears that appropriate progesterone levels can be achieved with hCG dosages as low as 375 IU. This may well optimize the chance of pregnancy while reducing the risk of OHSS associated with higher doses of hCG supplementation in the luteal phase.
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Affiliation(s)
- Barbara Lawrenz
- IVF Department, IVI Middle-East Fertility Clinic, Abu Dhabi, United Arab Emirates
- Obstetrical Department, Women’s University Hospital Tuebingen, Tuebingen, Germany
- *Correspondence: Barbara Lawrenz,
| | - Suzan Samir
- IVF Department, IVI Middle-East Fertility Clinic, Abu Dhabi, United Arab Emirates
| | | | - Laura Melado
- IVF Department, IVI Middle-East Fertility Clinic, Abu Dhabi, United Arab Emirates
| | - Nils Engelmann
- IVF Department, IVI Middle-East Fertility Clinic, Abu Dhabi, United Arab Emirates
| | - Human M. Fatemi
- IVF Department, IVI Middle-East Fertility Clinic, Abu Dhabi, United Arab Emirates
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Grazul-Bilska AT, Thammasiri J, Kraisoon A, Reyaz A, Bass CS, Kaminski SL, Navanukraw C, Redmer DA. Expression of progesterone receptor protein in the ovine uterus during the estrous cycle: Effects of nutrition, arginine and FSH. Theriogenology 2017; 108:7-15. [PMID: 29175682 DOI: 10.1016/j.theriogenology.2017.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 11/06/2017] [Accepted: 11/09/2017] [Indexed: 12/14/2022]
Abstract
To evaluate expression of progesterone receptor (PGR) AB in follicle stimulating hormone (FSH)-treated or non-treated sheep administered with arginine (Arg) or saline (Sal) fed a control (C), excess (O) or restricted (U) diet, uterine tissues were collected at the early, mid and/or late luteal phases. In exp. 1, ewes from each diet were randomly assigned to one of two treatments, Arg or Sal administration three times daily from day 0 of the first estrous cycle until uterine tissue collection. In exp. 2, ewes were injected twice daily with FSH on days 13-15 of the first estrous cycle. Uterine tissues were immunostained to detect PGR followed by image analysis. PGR were detected in luminal epithelium (LE), endometrial glands (EG), endometrial stroma (ES), myometrium (Myo), and endometrial and myometrial blood vessels. The percentage of PR-positive cells and/or intensity of staining were affected by phase of the estrous cycle, plane of nutrition, and/or FSH but not by Arg. In exp. 1, percentage of PGR-positive cells in LE and EG but not in ES and Myo was greater at the early and mid than late luteal phase, was not affected by plane of nutrition, and was similar in LE and EG. Intensity of staining was affected by phase of the estrous cycle and plane of nutrition in LE, EG and Myo, and was the greatest in LE, less in EG, and least in ES and Myo. In exp. 2, percentage of PGR-positive cells in LE, EG, ES and Myo was affected by phase of the estrous cycle, but not by plane of nutrition; was greater at the early than mid luteal phase; and was greatest in LE and EG, less in luminal (superficial) ES and Myo and least in deep ES. Intensity of staining was affected by phase of the estrous cycle and plane of nutrition in all compartments but ES, and was the greatest in LE and luminal EG, less in deep EG, and least in ES and Myo. Comparison of data for FSH (superovulated) and Sal-treated (non-superovulated) ewes demonstrated that FSH affected PR expression in all evaluated uterine compartments depending on plane of nutrition and phase of the estrous cycle. Thus, PGR are differentially distributed in uterine compartments, and PGR expression is affected by nutritional plane and FSH, but not Arg depending on phase of the estrous cycle. Such changes in dynamics of PGR expression indicate that diet plays a regulatory role and that FSH-treatment may alter uterine functions.
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Affiliation(s)
- Anna T Grazul-Bilska
- Department of Animal Sciences, North Dakota State University, Fargo, ND 58108, USA.
| | - Jiratti Thammasiri
- Agricultural Biotechnology Research Center for Sustainable Economy (ABRCSE), Department of Animal Science, Faculty of Agriculture, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Aree Kraisoon
- Agricultural Biotechnology Research Center for Sustainable Economy (ABRCSE), Department of Animal Science, Faculty of Agriculture, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Arshi Reyaz
- Department of Animal Sciences, North Dakota State University, Fargo, ND 58108, USA
| | - Casie S Bass
- Department of Animal Sciences, North Dakota State University, Fargo, ND 58108, USA
| | - Samantha L Kaminski
- Department of Animal Sciences, North Dakota State University, Fargo, ND 58108, USA
| | - Chainarong Navanukraw
- Agricultural Biotechnology Research Center for Sustainable Economy (ABRCSE), Department of Animal Science, Faculty of Agriculture, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Dale A Redmer
- Department of Animal Sciences, North Dakota State University, Fargo, ND 58108, USA
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Frozen embryo transfer can be performed in the cycle immediately following the freeze-all cycle. J Assist Reprod Genet 2017; 35:135-142. [PMID: 28939988 DOI: 10.1007/s10815-017-1048-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 09/12/2017] [Indexed: 10/18/2022] Open
Abstract
PURPOSE In this study, we investigated whether the time interval between oocyte retrieval and frozen embryo transfer (FET) affected the live birth (LB) rates of human segmented-IVF cycles. METHOD A total of 1338 ICSI freeze-all cycles were performed between February 2015 and January 2016, with 1121 FET cycles being retrospectively analyzed. All vitrified-warmed blastocyst transfers were performed in artificial FET cycles, using gonadotropin-releasing hormone (GnRH) agonist downregulation and oral estrogen endometrial preparation. The primary outcome measure was LB. Cycles were investigated in oocyte retrieval-to-FET interval groups of 32-46, 47-61, 62-76, 77-91, and ≥ 92 days, with the 47-61-day group used as the reference group. RESULTS There were no significant differences in LB rates between the groups in the overall analysis, as well as, in sub-analyses investigating LB in terms of single blastocyst transfer (SBT), trigger type (GnRH agonist, triggers including hCG), oocyte number (≤ 5 and ≥ 15), and maternal age (> 35 years). CONCLUSION The present study showed that it is feasible to perform transfers 36 days after oocyte retrieval and that delaying FET in freeze-all beyond the cycle immediately following oocyte retrieval does not increase LB rates.
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Tannus S, Burke Y, McCartney CR, Kol S. GnRH-agonist triggering for final oocyte maturation in GnRH-antagonist IVF cycles induces decreased LH pulse rate and amplitude in early luteal phase: a possible luteolysis mechanism. Gynecol Endocrinol 2017; 33:741-745. [PMID: 28440715 DOI: 10.1080/09513590.2017.1318275] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
The use of GnRH agonist to trigger final oocyte maturation in GnRH-antagonist in vitro fertilization (IVF) cycles has been shown to significantly reduce or even eliminate the risk of ovarian hyperstimulation syndrome (OHSS) by inducing rapid luteolysis early in the luteal phase. The exact mechanism of this early luteolysis is still widely unknown. Since luteinizing hormone (LH) has a major role in corpus luteum support, we sought to explore the pattern of LH secretion early in the luteal phase. Ten high risk patients for developing OHSS and triggered with GnRH agonist were included. Frequent blood sampling (every 20 min for 6 h) to measure LH, estradiol and progesterone was done on the day of oocyte collection (n = 5, Group 1) and on the day of embryo transfer, 48 h after oocyte collection (n = 5, Group 2). We found that the mean LH concentration and its secretion rate decreased significantly in Group 2 compared to Group 1. Both groups had similar number of LH pulses characterized by very small amplitude. In Group 2, there was a steady significant decrease in estradiol and progesterone over time. The results of this study show that LH secretion deviates significantly from normal physiologic pattern, which can explain, at least in part, the post-GnRH-agonist trigger early luteolysis mechanism.
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Affiliation(s)
- Samer Tannus
- a Department of Obstetrics and Gynecology , Rambam Health Care Campus , Haifa , Israel
- b McGill Reproductive Center, McGill University, Royal Victoria Hospital , Montreal, Québec
| | - Yechiel Burke
- a Department of Obstetrics and Gynecology , Rambam Health Care Campus , Haifa , Israel
| | - Christopher R McCartney
- c Division of Endocrinology and Metabolism (Department of Medicine) , Center for Research in Reproduction, University of Virginia School of Medicine , Charlottesville , Virginia , USA , and
| | - Shahar Kol
- a Department of Obstetrics and Gynecology , Rambam Health Care Campus , Haifa , Israel
- d The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology , Haifa , Israel
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Ovarian hyperstimulation syndrome following GnRH agonist trigger-think ectopic. J Assist Reprod Genet 2017; 34:1161-1165. [PMID: 28600619 DOI: 10.1007/s10815-017-0960-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 05/17/2017] [Indexed: 10/19/2022] Open
Abstract
PURPOSE This study aims to report a case of ovarian hyperstimulation syndrome (OHSS) following GnRH agonist trigger for final follicular maturation. METHODS This study is a retrospective chart review. RESULTS We report the first case of OHSS following GnRH agonist trigger for final follicular maturation and freeze-all, masking extrauterine pregnancy (EUP). The present case report elucidates the feasibility of stimulating and recruiting ovarian follicles yielding mature oocytes during early pregnancy and the ability of GnRH agonist to trigger final follicular maturation during pregnancy, in the presence of high progesterone and hCG levels. CONCLUSIONS Since OHSS almost always develops after hCG administration or in early pregnancy, its occurrence following GnRH agonist trigger should alert physician to search for either an inadvertent administration of exogenous hCG, or the endogenous secretion of hCG by pregnancy, e.g. EUP, or as part of a paraneoplastic syndrome.
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Lawrenz B, Garrido N, Samir S, Ruiz F, Melado L, Fatemi HM. Individual luteolysis pattern after GnRH-agonist trigger for final oocyte maturation. PLoS One 2017; 12:e0176600. [PMID: 28459828 PMCID: PMC5411051 DOI: 10.1371/journal.pone.0176600] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 04/13/2017] [Indexed: 11/18/2022] Open
Abstract
Final oocyte maturation using GnRH-agonist trigger in a GnRH-antagonist protocol is increasingly common, as ovarian hyperstimulation syndrome is almost completely avoided. However, this approach might lead to reduced pregnancy rates due to severe luteolysis. This proof of concept study evaluated the extend of luteolysis by measuring progesterone levels 48 hours after oocyte retrieval in 51 patients, who received GnRH-agonist trigger for final oocyte maturation in a GnRH-antagonist protocol due to the risk of ovarian hyperstimulation syndrome. It was shown, that luteolysis after GnRHa-trigger differs greatly among patients, with progesterone levels ranging from 13.0 ng/ml to ≥ 60.0 ng/ml, 48 hours after oocyte retrieval. Significant positive correlations could be demonstrated between progesterone levels and the number of ovarian stimulation and suppression days (p = 0.006 and p = 0.002 respectively), the total amount of medication used for ovarian suppression (p = 0.015), the level of progesterone on the day of final oocyte maturation (p = 0.008) and the number of retrieved oocytes (p = 0.019). Therefore it was concluded, that luteolysis after GnRH-agonist trigger is patient-specific and also luteal phase support requires individualization. Longer stimulation duration as well as a higher level of progesterone on the day of final oocyte maturation and more retrieved oocytes will result in higher levels of progesterone 48 hours after oocyte retrieval.
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Affiliation(s)
- Barbara Lawrenz
- IVF department, IVI Middle-East Fertility Clinic, Abu Dhabi, UAE
- Obstetrical Department, Women´s university hospital Tuebingen, Tuebingen, Germany
- * E-mail:
| | | | - Suzan Samir
- IVF department, IVI Middle-East Fertility Clinic, Abu Dhabi, UAE
| | - Francisco Ruiz
- IVF department, IVI Middle-East Fertility Clinic, Abu Dhabi, UAE
| | - Laura Melado
- IVF department, IVI Middle-East Fertility Clinic, Abu Dhabi, UAE
| | - Human M. Fatemi
- IVF department, IVI Middle-East Fertility Clinic, Abu Dhabi, UAE
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Lawrenz B, Ruiz F, Engelmann N, Fatemi HM. Individual luteolysis post GnRH-agonist-trigger in GnRH-antagonist protocols. Gynecol Endocrinol 2017; 33:261-264. [PMID: 28019139 DOI: 10.1080/09513590.2016.1266325] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Over the past few years, the use of Gonadotropin-releasing-hormone (GnRH)-agonist for final oocyte maturation in GnRH-antagonist-protocols in stimulated IVF/ICSI cycles has gained worldwide acceptance, as this approach reduces significantly the risk for development of ovarian hyperstimulation syndrome (OHSS). Final oocyte maturation with GnRH-agonist leads to sever luteolysis, which cannot be counterbalanced using standard luteal phase support with purely progesterone (P4) application and therefore administration of hCG or high doses of P4 is considered to be essential to prevent/counteract luteolysis. However, lately publications indicate, that luteolysis is not always complete after GnRH-agonist for trigger. This case-series evaluates the degree of luteolysis in high-responder-patients, who received GnRH-agonist for final oocyte maturation. Assessment of estradiol (E2)- and P4-levels 48 h after oocyte-pick-up (OPU) procedure demonstrate clearly, that luteolysis after GnRH-agonist trigger is individual-specific, even in high-responder patients with the same number of oocytes. Hence, individualization of luteal phase support with the focus on avoiding unnecessary administration of hCG, bearing the risk for development of OHSS, a new concept of luteal coasting needs to be developed, based on severity of luteolysis following luteal coasting.
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Affiliation(s)
- B Lawrenz
- a IVI Middle East Fertility Center , Marina Village, Abu Dhabi , UAE
| | - F Ruiz
- a IVI Middle East Fertility Center , Marina Village, Abu Dhabi , UAE
| | - N Engelmann
- a IVI Middle East Fertility Center , Marina Village, Abu Dhabi , UAE
| | - H M Fatemi
- a IVI Middle East Fertility Center , Marina Village, Abu Dhabi , UAE
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Dosouto C, Haahr T, Humaidan P. Gonadotropin-releasing hormone agonist (GnRHa) trigger – State of the art. Reprod Biol 2017; 17:1-8. [DOI: 10.1016/j.repbio.2017.01.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/04/2017] [Accepted: 01/05/2017] [Indexed: 02/07/2023]
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Grazul-Bilska AT, Khanthusaeng V, Bass CS, Kaminski SL, Navanukraw C, Redmer DA. Lipid droplets in the ovine uterus during the estrous cycle: Effects of nutrition, arginine, and FSH. Theriogenology 2017; 87:212-220. [DOI: 10.1016/j.theriogenology.2016.08.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 08/14/2016] [Accepted: 08/25/2016] [Indexed: 12/20/2022]
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Alyasin A, Mehdinejadiani S, Ghasemi M. GnRH agonist trigger versus hCG trigger in GnRH antagonist in IVF/ICSI cycles: A review article. Int J Reprod Biomed 2016. [DOI: 10.29252/ijrm.14.9.557] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Connell MT, Patounakis G, Healy MW, DeCherney AH, Devine K, Widra E, Levy MJ, Hill MJ. Is the effect of premature elevated progesterone augmented by human chorionic gonadotropin versus gonadotropin-releasing hormone agonist trigger? Fertil Steril 2016; 106:584-589.e1. [PMID: 27178228 DOI: 10.1016/j.fertnstert.2016.04.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 03/25/2016] [Accepted: 04/13/2016] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To compare the effect of P on live birth rate between hCG and GnRH agonist (GnRH-a) trigger cycles. DESIGN Retrospective cohort study. SETTING Large private assisted reproductive technology (ART) practice. PATIENT(S) A total of 3,326 fresh autologous ART cycles. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Live birth. RESULT(S) A total of 647 GnRH-a trigger cycles were compared with 2,679 hCG trigger cycles. Live birth was negatively associated with P in both the hCG trigger (odds ratio [OR] 0.62, 95% confidence interval [CI] 0.52-0.76) and the agonist trigger cohorts (OR 0.56, 95% CI 0.45-0.69). Interaction testing evaluating P and trigger medication was not significant, indicating that P had a similar negative effect on live birth rates in both cohorts. Progesterone ≥2 ng/mL occurred more commonly in GnRH-a trigger cycles compared with hCG trigger cycles (5.5% vs. 3.1%) and was negatively associated with live birth in both the hCG trigger (OR 0.28, 95% CI 0.11-0.73) and agonist trigger cohorts (OR 0.35, 95% CI 0.14-0.90). When P ≥2 ng/mL, the live birth rates were poor and similar in the hCG and GnRH-a cohorts (5.9% vs. 14.2%), indicating that P ≥2 ng/mL had a similar negative effect on live birth in both cohorts. CONCLUSION(S) Elevated serum P on the day of hCG was negatively associated with live birth rates in both hCG and GnRH-a trigger cycles.
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Affiliation(s)
- Matthew T Connell
- Shady Grove Fertility Reproductive Science Center, Rockville, Maryland; Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - George Patounakis
- Shady Grove Fertility Reproductive Science Center, Rockville, Maryland; Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Mae Wu Healy
- Shady Grove Fertility Reproductive Science Center, Rockville, Maryland; Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Alan H DeCherney
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Kate Devine
- Shady Grove Fertility Reproductive Science Center, Rockville, Maryland
| | - Eric Widra
- Shady Grove Fertility Reproductive Science Center, Rockville, Maryland
| | - Michael J Levy
- Shady Grove Fertility Reproductive Science Center, Rockville, Maryland
| | - Micah J Hill
- Shady Grove Fertility Reproductive Science Center, Rockville, Maryland; Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland.
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Ozgur K, Humaidan P, Coetzee K. Segmented ART - The new era in ART? Reprod Biol 2016; 16:91-103. [PMID: 27288333 DOI: 10.1016/j.repbio.2016.04.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 03/29/2016] [Accepted: 04/03/2016] [Indexed: 01/31/2023]
Abstract
Currently up to 4% of infants born in developing countries are conceived through assisted reproductive technology (ART). Even though most of these conceptions occur and progress without complications, ART procedures and processes may increase iatrogenesis through complications in - and after conception. We herein review and discuss the clinically and scientific implications and evidence of iatrogenesis, and show how the evolution in ART technologies and procedures has led to the current presumption that frozen embryo transfer might be a more optimal strategy than fresh embryo transfer, in terms of not only reproduction, but also of maternal and fetal outcomes. There is increasing scientific evidence to support the notion that controlled ovarian stimulation could induce significant changes to the endocrine profile of a reproductive cycle, especially to the reproductively important early luteal phase. These changes may not only have a negative effect on implantation and early placentation, but also on the mother, the fetus, and the infant. The overt consequences of controlled ovarian stimulation include ovarian hyperstimulation syndrome, reduced embryo implantation, increased ectopic pregnancy, and altered placentation and fetal growth. The cumulative scientific evidence from this review suggests that GnRHa trigger in segmented ART might constitute the future routine treatment regimen for IVF patients, providing a safe, effective, and patient friendly treatment.
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Affiliation(s)
| | - Peter Humaidan
- The Fertility Clinic, Skive Regional Hospital and Faculty of Health, Aarhus University, Aarhus, Denmark
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Kol S, Breyzman T. GnRH agonist trigger does not always cause luteolysis: a case report. Reprod Biomed Online 2016; 32:132-4. [DOI: 10.1016/j.rbmo.2015.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 08/26/2015] [Accepted: 09/10/2015] [Indexed: 10/22/2022]
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Gurbuz AS, Deveer R, Ozcimen N, Ozcimen EE, Lawrenz B, Banker M, Garcia-Velasco JA, Fatemi HM. Absence of luteal phase defect and spontaneous pregnancy in IVF patients despite GnRH-agonist trigger and "freeze all policy" without luteal phase support: a report of four cases. Gynecol Endocrinol 2016; 32:18-20. [PMID: 26487486 DOI: 10.3109/09513590.2015.1110694] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [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
Human chorionic gonadotropin (hCG) is commonly used for final oocyte maturation in "in vitro fertilization" (IVF)-treatment cycles, however, the main important risk is development of severe ovarian hyperstimulation syndrome (OHSS). OHSS can almost be avoided by using gonadotrophin-releasing-hormone agonist for final oocyte maturation in an antagonist protocol. However, primarily this approach lead to a very poor reproductive outcome, despite the use of a standard luteal phase support. The reason seems to be severe luteolysis. Obviously, luteolysis post-gonadotropin-releasing-hormone-agonist (post-GnRH-a) trigger is individual specific, and not all patients will develop a complete luteolysis, as expected previously. Luteolysis can been reverted by the administration of hCG. Unprotected intercourse around the time of ovulation induction and oocyte retrieval can lead to a spontaneous conception in IVF treatment and, endogenous hCG, produced by the trophoblast, will rescue the corpora lutea. Therefore, one should not rely on complete luteolysis after GnRH-a triggering and, especially patients for egg donation and pre-implantation-genetic diagnosis for single gene disorder, have to be counselled to avoid unprotected intercourse.
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Affiliation(s)
| | - Ruya Deveer
- b Department of Obstetrics and Gynecology , Mugla Sitki Kocman University, Medical Facility , Mugla , Turkey
| | | | - Emel Ebru Ozcimen
- c Department of Obstetrics and Gynecology , Baskent University, Medical Faculty , Konya , Turkey
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Decleer W, Verschueren K, Vandeginste S, Osmanagaoglu K, Devroey P. Corifollitropin stimulation in combination with GnRH-antagonists after estradiol valerate pre-treatment. A pilot study on patientfriendly IVF. Facts Views Vis Obgyn 2015; 7:223-230. [PMID: 27729967 PMCID: PMC5058411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To demonstrate the feasibility of scheduling an IVF cycle, without disadvantages, in the new patient friendly stimulation protocol using the long acting Corifollitropin Alfa, in combination with GnRH-antagonist protection and GnRH-agonist triggering. STUDY DESIGN Two groups of ten patients were admitted in the study. Both received the same stimulation protocol with Corifollitropin Alfa in combination with GnRH-antagonist protection. After ultrasound evaluation on day 7 individually dosed Menopur was added. For triggering final oocyte maturation GnRH-agonists were used. The only difference between the two groups was that in the study group, estradiol valerate 4 mg/day was given from day 25 of the preceding cycle for a period of 10 days, thus postponing the start of follicular growth. RESULTS Scheduling the IVF stimulation by the administration of estradiol valerate 4 mg/day did not influence the hormonal curves, nor the embryological results in comparison to patients with the same stimulation, starting their stimulation at the beginning of menstruation. In this pilot study four out of ten patients turned out to be pregnant, demonstrating an acceptable pregnancy rate. CONCLUSION The combination of estradiol valerate 4 mg/day pre-treatment with the novel combination of Corifollitropin Alfa stimulation with GnRH-antagonist protection, individually topped off with Menopur, and triggered with GnRH-agonist proved to be a safe, patient-friendly (limited number of injections in comparison to classical IVF) (Patil, 2014) and efficient alternative to classical IVF stimulation protocols, allowing patients - and doctors - to schedule the treatment cycle to their convenience.
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Affiliation(s)
- W Decleer
- Fertility center, AZ Jan Palfijn Hospital, Henri Dunantlaan 5, 9000 Gent, Belgium
| | - K Verschueren
- Living Statistics, Kunstenaarstraat 35, 9040 Sint-Amandsberg, Belgium
| | | | - K Osmanagaoglu
- Fertility center, AZ Jan Palfijn Hospital, Henri Dunantlaan 5, 9000 Gent, Belgium
| | - P Devroey
- Fertility center, AZ Jan Palfijn Hospital, Henri Dunantlaan 5, 9000 Gent, Belgium
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Kol S, Breyzman T, Segal L, Humaidan P. ‘Luteal coasting’ after GnRH agonist trigger – individualized, HCG-based, progesterone-free luteal support in ‘high responders’: a case series. Reprod Biomed Online 2015; 31:747-51. [DOI: 10.1016/j.rbmo.2015.09.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 08/17/2015] [Accepted: 09/02/2015] [Indexed: 10/23/2022]
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Affiliation(s)
- Gautam N Allahbadia
- Rotunda-The Center For Human Reproduction, Mumbai, India ; New Hope IVF, Sharjah, UAE
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Avoiding ovarian hyperstimulation syndrome with the use of gonadotropin-releasing hormone agonist trigger. Fertil Steril 2015; 103:870-3. [DOI: 10.1016/j.fertnstert.2015.02.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Revised: 02/04/2015] [Accepted: 02/04/2015] [Indexed: 01/20/2023]
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Connell MT, Szatkowski JM, Terry N, DeCherney AH, Propst AM, Hill MJ. Timing luteal support in assisted reproductive technology: a systematic review. Fertil Steril 2015; 103:939-946.e3. [PMID: 25638420 DOI: 10.1016/j.fertnstert.2014.12.125] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 12/10/2014] [Accepted: 12/30/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To summarize the available published randomized controlled trial data regarding timing of P supplementation during the luteal phase of patients undergoing assisted reproductive technology (ART). DESIGN A systematic review. SETTING Not applicable. PATIENT(S) Undergoing IVF. INTERVENTION(S) Different starting times of P for luteal support. MAIN OUTCOME MEASURE(S) Clinical pregnancy (PR) and live birth rates. RESULT(S) Five randomized controlled trials were identified that met inclusion criteria with a total of 872 patients. A planned meta-analysis was not performed because of a high degree of clinical heterogeneity with regard to the timing, dose, and route of P. Two studies compared P initiated before oocyte retrieval versus the day of oocyte retrieval and PRs were 5%-12% higher when starting P on the day of oocyte retrieval. One study compared starting P on day 6 after retrieval versus day 3, reporting a 16% decrease in pregnancy in the day 6 group. Trials comparing P start times on the day of oocyte retrieval versus 2 or 3 days after retrieval showed no significant differences in pregnancy. CONCLUSION(S) There appears to be a window for P start time between the evening of oocyte retrieval and day 3 after oocyte retrieval. Although some studies have suggested a potential benefit in delaying vaginal P start time to 2 days after oocyte retrieval, this review could not find randomized controlled trials to adequately assess this. Further randomized clinical trials are needed to better define P start time for luteal support after ART.
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Affiliation(s)
- Matthew T Connell
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Jennifer M Szatkowski
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Nancy Terry
- National Institutes of Health Library, Bethesda, Maryland
| | - Alan H DeCherney
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | | | - Micah J Hill
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland.
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