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Harvey AJ, Willson BE, Surrey ES, Gardner DK. Ovarian stimulation protocols: impact on oocyte and endometrial quality and function. Fertil Steril 2024:S0015-0282(24)01973-3. [PMID: 39197516 DOI: 10.1016/j.fertnstert.2024.08.340] [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: 07/27/2024] [Revised: 08/19/2024] [Accepted: 08/21/2024] [Indexed: 09/01/2024]
Abstract
Ovarian stimulation (OS) truly is an art. There exists a myriad of protocols used to achieve the same goal: stimulating the ovaries to produce more than one mature oocyte to improve the chance of a live birth. However, considerable debate remains as to whether OS impacts oocyte and endometrial quality to affect in vitro fertilization outcomes. Although "more is better" has long been considered the best approach for oocyte retrieval, this review challenges that notion by examining the influence of stimulation on oocyte quality. Likewise, improved outcomes after frozen blastocyst transfer suggest that OS perturbs endometrial preparation and/or receptivity, although correlating changes with implantation success remains a challenge. Therefore, the focus of this review is to summarize our current understanding of perturbations in human oocyte quality and endometrial function induced by exogenous hormone administration. We highlight the need for further research to identify more appropriate markers of oocyte developmental competence as well as those that define the roles of the endometrium in the success of assisted reproductive technology.
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Affiliation(s)
- Alexandra J Harvey
- Melbourne IVF, East Melbourne, Victoria, Australia; School of BioSciences, University of Melbourne, Parkville, Victoria, Australia
| | - Bryn E Willson
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Cedars Sinai, Los Angeles, California
| | - Eric S Surrey
- Colorado Center for Reproductive Medicine, Lone Tree, Colorado
| | - David K Gardner
- Melbourne IVF, East Melbourne, Victoria, Australia; School of BioSciences, University of Melbourne, Parkville, Victoria, Australia.
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2
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Wang Q, Wan Q, Li T, Wang X, Hu Y, Zhong Z, Pu K, Ding Y, Tang X. Effect of GnRH agonist trigger with or without low-dose hCG on reproductive outcomes for PCOS women with freeze-all strategy: a propensity score matching study. Arch Gynecol Obstet 2024; 309:679-688. [PMID: 38032411 DOI: 10.1007/s00404-023-07285-1] [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: 08/11/2023] [Accepted: 10/31/2023] [Indexed: 12/01/2023]
Abstract
PURPOSE This study aimed to compare the effect of gonadotropin-releasing hormone agonist (GnRHa) trigger alone versus dual trigger comprising GnRHa and low-dose human chorionic gonadotropin (hCG) on reproductive outcomes in patients with polycystic ovary syndrome (PCOS) who received the freeze-all strategy. METHODS A total of 615 cycles were included in this retrospective cohort study. Propensity score matching (PSM) was performed to control potential confounding factors between GnRHa-trigger group (0.2 mg GnRHa) and dual-trigger group (0.2 mg GnRHa plus 1000/2000 IU hCG) in a 1:1 ratio. Multivariate logistic regression was applied to estimate the association between trigger methods and reproductive outcomes. RESULTS After PSM, patients with dual trigger (n = 176) had more oocytes retrieved, mature oocytes, and 2PN embryos compared to that with GnRHa trigger alone. However, the oocytes maturation rate, normal fertilization rate, and frozen embryos between the two groups were not statistically different. The incidence of ovarian hyperstimulation syndrome (OHSS) (14.8% vs. 2.8%, P < 0.001) and moderate/severe OHSS (11.4% vs. 1.7%, P < 0.001) were significantly higher in dual-trigger group than in GnRHa-alone group. Logistic regression analysis showed the adjusted odds ratio of dual trigger was 5.971 (95% confidence interval 2.201-16.198, P < 0.001) for OHSS. The pregnancy and single neonatal outcomes were comparable between the two groups (P > 0.05). CONCLUSION For PCOS women with freeze-all strategy, GnRHa trigger alone decreased the risk of OHSS without damaging oocyte maturation and achieved satisfactory pregnancy outcomes.
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Affiliation(s)
- Qiaofeng Wang
- Department of Epidemiology, School of Public Health, Chongqing Medical University, Chongqing, China
- Chongqing University Three Gorges Hospital, Wanzhou, Chongqing, China
| | - Qi Wan
- Department of Gynecology and Obstetrics, West China Second Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Tian Li
- Department of Reproductive Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xuejiao Wang
- Department of Reproductive Center, Chengdu Jinjiang Hospital for Women's and Children's Health, Chengdu, China
| | - Yuling Hu
- Department of Reproductive Center, Chengdu Jinjiang Hospital for Women's and Children's Health, Chengdu, China
| | - Zhaohui Zhong
- Department of Epidemiology, School of Public Health, Chongqing Medical University, Chongqing, China
| | - Kexue Pu
- Chongqing Engineering Research Center for Clinical Big Data and Drug Evaluation, College of Medical Informatics, Chongqing Medical University, Chongqing, China
| | - Yubin Ding
- Joint International Research Laboratory of Reproduction and Development of the Ministry of Education of China, School of Public Health, Chongqing Medical University, Chongqing, China.
- Department of Obstetrics and Gynecology, Women and Children's Hospital of Chongqing Medical University, Chongqing Medical University, Chongqing, China.
| | - Xiaojun Tang
- Department of Epidemiology, School of Public Health, Chongqing Medical University, Chongqing, China.
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3
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Machtinger R, Racowsky C, Baccarelli AA, Bollati V, Orvieto R, Hauser R, Barnett-Itzhaki Z. Recombinant human chorionic gonadotropin and gonadotropin-releasing hormone agonist differently affect the profile of extracellular vesicle microRNAs in human follicular fluid. J Assist Reprod Genet 2023; 40:527-536. [PMID: 36609942 PMCID: PMC10033801 DOI: 10.1007/s10815-022-02703-w] [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: 07/16/2022] [Accepted: 12/19/2022] [Indexed: 01/08/2023] Open
Abstract
PURPOSE To compare the expression profile of extracellular vesicle microRNAs (EV-miRNAs) derived from follicular fluid after a trigger with recombinant human chorionic gonadotropin (r-hCG) or with a gonadotropin-releasing hormone GnRH agonist (GnRH-a) for final oocyte maturation. METHODS A retrospective analysis of a prospective cohort. Women undergoing in vitro fertilization at a tertiary university-affiliated hospital were recruited between 2014 and 2016. EV-miRNAs were extracted from the follicular fluid of a single follicle, and their expression was assessed using TaqMan Open Array®. Genes regulated by EV-miRNAs were analyzed using miRWalk2.0 Targetscan database, DAVID Bioinformatics Resources, Kyoto-Encyclopedia of Genes and Genomes (KEGG), and Gene Ontology (GO). RESULTS Eighty-two women were included in the r-hCG trigger group and 9 in the GnRH-a group. Of 754 EV-miRNAs screened, 135 were detected in at least 50% of the samples and expressed in both groups and were further analyzed. After adjusting for multiple testing, 41 EV-miRNAs whose expression levels significantly differed between the two trigger groups were identified. Bioinformatics analysis of the genes regulated by these EV-miRNAs showed distinct pathways between the two triggers, including TGF-beta signaling, cell cycle, and Wnt signaling pathways. Most of these pathways regulate cascades associated with apoptosis, embryo development, implantation, decidualization, and placental development. CONCLUSIONS Trigger with GnRH-a or r-hCG leads to distinct EV-miRNAs expression profiles and to downstream biological effects in ovarian follicles. These findings may provide an insight for the increased apoptosis and the lower implantation rates following GnRH-a trigger vs. r-hCG in cases lacking intensive luteal phase support.
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Affiliation(s)
- R Machtinger
- Department of Obstetrics and Gynecology, Division of IVF, Sheba Medical Center, Ramat Gan 5262000, Israel.
- Sackler School of Medicine, Tel-Aviv University, 6997801, Tel Aviv, Israel.
| | - C Racowsky
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
| | - A A Baccarelli
- Laboratory of Precision Environmental Biosciences, Department of Environmental Health Sciences, Columbia Mailman School of Public Health, New York, NY, 10032, USA
| | - V Bollati
- EPIGET Lab, Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, 20122, Milan, Italy
- Occupational Health Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122, Milan, Italy
| | - R Orvieto
- Department of Obstetrics and Gynecology, Division of IVF, Sheba Medical Center, Ramat Gan 5262000, Israel
| | - R Hauser
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
| | - Z Barnett-Itzhaki
- Public Health Services, Ministry of Health, 9446724, Jerusalem, Israel
- Faculty of Engineering, Ruppin Academic Center, 4025000, Emek Hefer, Israel
- Ruppin Research Group in Environmental and Social Sustainability, Ruppin Academic Center, 4025000, Emek Hefer, Israel
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Drakopoulos P, Khalaf Y, Esteves SC, Polyzos NP, Sunkara SK, Shapiro D, Rizk B, Ye H, Costello M, Koloda Y, Salle B, Lispi M, D'Hooghe T, La Marca A. Treatment algorithms for high responders: What we can learn from randomized controlled trials, real-world data and models. Best Pract Res Clin Obstet Gynaecol 2023; 86:102301. [PMID: 36646567 DOI: 10.1016/j.bpobgyn.2022.102301] [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: 11/21/2022] [Accepted: 12/19/2022] [Indexed: 12/28/2022]
Abstract
A high ovarian response to conventional ovarian stimulation (OS) is characterized by an increased number of follicles and/or oocytes compared with a normal response (10-15 oocytes retrieved). According to current definitions, a high response can be diagnosed before oocyte pick-up when >18-20 follicles ≥11-12 mm are observed on the day of ovulation triggering; high response can be diagnosed after oocyte pick-up when >18-20 oocytes have been retrieved. Women with a high response are also at high risk of early ovarian hyper-stimulation syndrome (OHSS)/or late OHSS after fresh embryo transfers. Women at risk of high response can be diagnosed before stimulation based on several indices, including ovarian reserve markers (anti-Müllerian hormone [AMH] and antral follicle count [AFC], with cutoff values indicative of a high response in patients with PCOS of >3.4 ng/mL for AMH and >24 for AFC). Owing to the high proportion of high responders who are at the risk of developing OHSS (up to 30%), this educational article provides a framework for the identification and management of patients who fall into this category. The risk of high response can be greatly reduced through appropriate management, such as individualized choice of the gonadotropin starting dose, dose adjustment based on hormonal and ultrasound monitoring during OS, the choice of down-regulation protocol and ovulation trigger, and the choice between fresh or elective frozen embryo transfer. Appropriate management strategies still need to be defined for women who are predicted to have a high response and those who have an unexpected high response after starting treatment.
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Affiliation(s)
- Panagiotis Drakopoulos
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium; Department of Obstetrics and Gynaecology, University of Alexandria, Alexandria, 21526, Egypt.
| | - Yakoub Khalaf
- Reproductive Medicine and Surgery, Guy's and St Thomas' NHS Foundation Trust, King's College London, London, United Kingdom
| | - Sandro C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Campinas, Brazil; Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Nikolaos P Polyzos
- Department of Reproductive Medicine, Dexeus University Hospital, 08028, Barcelona, Spain; Faculty of Medicine and Health Sciences, University of Ghent (UZ Gent), 9000, Gent, Belgium
| | - Sesh K Sunkara
- Department of Women's Health, Faculty of Life Sciences and Medicine, King's College London, Great Maze Pond, London, United Kingdom
| | | | - Botros Rizk
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of South Alabama, Mobile, AL, 36604, USA
| | - Hong Ye
- Chongqing Key Laboratory of Human Embryo Engineering, Chongqing, China; Chongqing Clinical Research Center for Reproductive Medicine, Chongqing, China; Reproductive and Genetic Institute, Chongqing Health Center for Women and Children, No. 64 Jin Tang Street, Yu Zhong District, Chongqing, 400013, China
| | - Michael Costello
- Division of Obstetrics & Gynaecology, School of Women's and Children's Health, UNSW and Royal Hospital for Women and Monash IVF, Sydney, Australia
| | - Yulia Koloda
- Center of Reproduction "Life Line", Moscow, Russia; Department of Obstetrics and Gynecology, Russian Medical Academy of Continuous Professional Education, Moscow, Russia
| | - Bruno Salle
- Department of Reproductive Medicine, CHU Lyon, Hôpital Femme Mère Enfant, 59 Bd Pinel, 69500, Bron, France; Université Claude Bernard, Faculté de Médecine Lyon Sud, 165 Chemin Du Petit Revoyet, Oullins, France; INSERM Unité, 1208, 18 Avenue Doyen Lépine, Bron, France
| | - Monica Lispi
- Merck Healthcare KGaA, Darmstadt, Germany; PhD School of Clinical and Experimental Medicine, Unit of Endocrinology, University of Modena and Reggio Emilia, Italy
| | - Thomas D'Hooghe
- Merck Healthcare KGaA, Darmstadt, Germany; Department of Development and Regeneration, Laboratory of Endometrium, Endometriosis & Reproductive Medicine, KU Leuven, Leuven, Belgium; Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University Medical School, New Haven, USA
| | - Antonio La Marca
- Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, and Clinica Eugin, Modena, Italy
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Safrai M, Hertsberg S, Ben-Meir A, Reubinoff B, Imbar T, Mordechai-Daniel T, Alexander S. Dydrogesterone supplementation in addition to routine micronized progesterone administration for luteal support in cycles triggered with lone GnRH agonist results in an acceptable pregnancy rate and avoids the need to freeze embryos. Minerva Obstet Gynecol 2023; 75:39-44. [PMID: 34904585 DOI: 10.23736/s2724-606x.21.04954-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Ovarian hyperstimulation syndrome (OHSS) is reduced when using antagonist cycle with gonadotrophin releasing hormone (GnRH) agonist trigger before ovum pick up. This trigger induces short luteinizing hormone (LH) and follicle stimulating hormone (FSH) peaks, resulting in an inadequate luteal phase and a reduced implantation rate. We assessed whether the luteal phase can be rescued by supplementing with oral dydrogesterone (duphaston) in antagonist cycles after a lone GnRH agonist trigger. METHODS A retrospective cohort study. The study group (N.=123) included women who underwent IVF. Patients received a GnRH-antagonist with a lone GnRH-agonist trigger due to imminent OHSS. The control group (N.=374) included patients who underwent a standard antagonist protocol with a dual trigger of a GnRH-agonist and human chorionic gonadotrophin (hCG). All the patients were treated with micronized progesterone (utrogestan) for luteal phase support. Study patients were given duphaston in addition. RESULTS The fertilization rate was comparable between the two groups. The mean number of embryos transferred, the clinical pregnancy rate and the take-home baby rate were comparable between groups (1.5±0.6 vs. 1.5±0.5 and 46.3% vs. 41.2%, and 66.7% vs. 87.7%, respectively). No OHSS event was reported in either group. CONCLUSIONS This study was the first to evaluate outcomes of duphaston supplementation for luteal support in an antagonist cycle with lone GnRH agonist trigger. The functionality of the luteal phase of those cycles could be restored by adding duphaston. This approach was found to be safe and prevented the need to postpone embryo transfer in case of pending OHSS.
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Affiliation(s)
- Myriam Safrai
- IVF Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel -
| | - Shmuel Hertsberg
- IVF Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Assaf Ben-Meir
- IVF Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | - Tal Imbar
- IVF Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | - Simon Alexander
- IVF Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Jirge PR, Patil MM, Gutgutia R, Shah J, Govindarajan M, Roy VS, Kaul-Mahajan N, Sharara FI. Ovarian Stimulation in Assisted Reproductive Technology Cycles for Varied Patient Profiles: An Indian Perspective. J Hum Reprod Sci 2022; 15:112-125. [PMID: 35928474 PMCID: PMC9345274 DOI: 10.4103/jhrs.jhrs_59_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/21/2022] [Accepted: 06/23/2022] [Indexed: 11/10/2022] Open
Abstract
Controlled ovarian stimulation has been an integral part of in vitro fertilisation (IVF) treatment cycles. Availability of different gonadotropins for ovarian stimulation and gonadotropin releasing hormone (GnRH) analogues for prevention of premature rise of leutinising hormone during follicular phase offer an opportunity to utilise them for a successful outcome in women with different subsets of ovarian response. Further, use of GnRH agonist as an alternative for human chorionic gonadotropin improves safety of ovarian stimulation in hyper-responders. Mild ovarian stimulation protocols have emerged as an alternative to conventional protocols in the recent years. Individualisation plays an important role in improving safety of IVF in hyper-responders while efforts continue to improve efficacy in poor responders. Some of the follicular and peri-ovulatory phase interventions may be associated with negative impact on the luteal phase and segmentalisation of the treatment with frozen embryo transfer may be an effective strategy in such a clinical scenario. This narrative review looks at the available evidence on various aspects of ovarian stimulation strategies and their consequences. In addition, it provides a concise summary of the evidence that has emerged from India on various aspects of ovarian stimulation.
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Affiliation(s)
- Padma Rekha Jirge
- Shreyas Hospital and Sushrut Assisted Conception Clinic, Kohlhapur, India
| | | | | | - Jatin Shah
- Mumbai Fertility Clinic & IVF Centre, Mumbai, India
| | | | | | | | - Faddy I Sharara
- Virginia Center for Reproductive Medicine, Reston; Department of O&G, George Washington University, Washington, DC, USA
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7
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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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Martazanova B, Mishieva N, Vedikhina I, Kirillova A, Korneeva I, Ivanets T, Abubakirov A, Sukhikh GT. Hormonal profile in early luteal phase after triggering ovulation with gonadotropin-releasing hormone agonist in high-responder patients. Front Endocrinol (Lausanne) 2022; 13:834627. [PMID: 36046787 PMCID: PMC9420862 DOI: 10.3389/fendo.2022.834627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 07/19/2022] [Indexed: 11/26/2022] Open
Abstract
The major limitations associated with gonadotropin-releasing hormone agonist (GnRHa) triggering are inferior clinical outcomes in fresh embryo transfer cycles caused by luteal phase insufficiency following the GnRHa triggering. We included 153 high-risk patients in this study. In group I, the patients received gonadotropin-releasing hormone agonist (GnRHa) trigger + 1,500 IU human chorionic gonadotropin (hCG) support on the oocyte pick-up (OPU) day; in group II, the patients had a dual trigger (GnRHa + 1,500 IU hCG); and in group III (control), 10,000 IU hCG trigger was prescribed for the final oocyte maturation. The levels of LH, estradiol, and progesterone were evaluated in serum on the stimulation starting day, day 6 of stimulation, on the day of the trigger administration, OPU day, days 3 and 5 post-OPU, and day 14 post-ET, as well as in follicular fluid. Progesterone concentration was significantly lower in group I on OPU+5 compared to the hCG group (I vs. III, р = 0.0065). Progesterone levels were significantly lower in group II in serum on OPU+5 compared to groups I and III (I vs. II, р = 0.0068; II vs. III, р = 1.76 × 108). The progesterone levels were significantly higher in follicular fluid in group III compared to the study groups (I vs. III, р = 0.002; II vs. III, p = 0.009). However, no significant differences in clinical outcomes were found between the groups. Then, we divided all women into pregnant and non-pregnant groups and found that estradiol (p = 0.00009) and progesterone (p = 0.000036) on the day of the pregnancy test were significantly higher in the pregnant women group. Also, progesterone on OPU day was significantly higher in the non-pregnant group (p = 0.033). Two cases of moderate ovarian hyperstimulation syndrome (OHSS) late-onset occurred in group I (3.5%, 2/56), no case of moderate/severe OHSS late-onset in group II, and three cases of moderate late-onset in group III (5.7%, 3/53). The low-dose hCG supplementation improves the luteal phase insufficiency after GnRHa triggering, which is confirmed by the comparable pregnancy rates in fresh transfer cycles between the groups. However, low-dose hCG carries a similar risk of OHSS as the full dose of hCG in high-responder patients.
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Dashti S, Eftekhar M. Luteal-phase support in assisted reproductive technology: An ongoing challenge. Int J Reprod Biomed 2021; 19:761-772. [PMID: 34723055 PMCID: PMC8548747 DOI: 10.18502/ijrm.v19i9.9708] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 12/02/2020] [Accepted: 12/12/2020] [Indexed: 01/06/2023] Open
Abstract
It has been shown that in controlled ovarian hyper stimulation cycles, defective
luteal phase is common. There are many protocols for improving pregnancy
outcomes in women undergoing fresh and frozen in vitro fertilization cycles.
These approaches include progesterone supplements, human chorionic gonadotropin,
estradiol, gonadotropin-releasing hormone agonist, and recombinant luteinizing
hormone. The main challenge is luteal-phase support (LPS) in cycles with
gonadotropin-releasing hormone agonist triggering. There is still controversy
about the optimal component and time for starting LPS in assisted reproductive
technology cycles. This review aims to summarize the various protocols suggested
for LPS in in vitro fertilization cycles.
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Affiliation(s)
- Saeideh Dashti
- Research and Clinical Center for Infertility, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Maryam Eftekhar
- Research and Clinical Center for Infertility, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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Conforti A, Carbone L, Iorio GG, Cariati F, Bagnulo F, Marrone V, Strina I, Alviggi C. Luteal Phase Support Using Subcutaneous Progesterone: A Systematic Review. FRONTIERS IN REPRODUCTIVE HEALTH 2021; 3:634813. [PMID: 36303972 PMCID: PMC9580777 DOI: 10.3389/frph.2021.634813] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 06/25/2021] [Indexed: 09/07/2024] Open
Abstract
Luteal phase support (LPS) is crucial in assisted reproductive technology (ART) cycles when the luteal phase has been found to be defective. Such deficiency is most likely related to the supraphysiological steroid levels that usually occurr in stimulated cycles which, in turn, could severely affect luteinizing hormone (LH) secretion and function, thereby negatively influencing the luteal phase. A number of different medications and routes have been successfully used for LPS in ART. Although an optimal protocol has not yet been identified, the existing plethora of medications offer the opportunity to personalize LPS according to individual needs. Subcutaneous administration progesterone has been proposed for LPS and could represent an alternative to a vaginal and intramuscular route. The aim of the present systematic review is to summarize the evidence found in the literature concerning the application of subcutaneous progesterone in ARTs, highlighting the benefits and limits of this novel strategy. With this aim in mind, we carried out systematic research in the Medline, ISI Web of Knowledge, and Embase databases from their inception through to November 2020. Randomized controlled trials (RCTs) were preferred by the authors in the elaboration of this article, although case-control and cohort studies have also been considered. According to our findings, evidence exists which supports that, in women with a good prognosis undergoing a fresh in vitro fertilization (IVF) cycle, subcutaneous Pg is not inferior to vaginal products. In the Frozen-thawed embryo transfer (FET) cycle, data concerning efficacy is mixed with an increased miscarriage rate in women undergoing a subcutaneous route in oocyte donor recipients. Data concerning the acceptance of the subcutaneous route versus the vaginal route are encouraging despite the different scales and questionnaires which were used. In addition, a cost-effective analysis has not yet been conducted.
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Affiliation(s)
- Alessandro Conforti
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Luigi Carbone
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Giuseppe Gabriele Iorio
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples Federico II, Naples, Italy
| | | | | | | | - Ida Strina
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Carlo Alviggi
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples Federico II, Naples, Italy
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11
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Ata B. Haste makes waste: don't rush for a fresh embryo transfer in high responders. Hum Reprod 2021; 35:2660-2662. [PMID: 33011785 DOI: 10.1093/humrep/deaa257] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Barış Ata
- Department of Obstetrics and Gynecology, Koç University School of Medicine, Istanbul, Turkish Republic
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12
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Santos-Ribeiro S, Mackens S, Popovic-Todorovic B, Racca A, Polyzos NP, Van Landuyt L, Drakopoulos P, de Vos M, Tournaye H, Blockeel C. The freeze-all strategy versus agonist triggering with low-dose hCG for luteal phase support in IVF/ICSI for high responders: a randomized controlled trial. Hum Reprod 2021; 35:2808-2818. [PMID: 32964939 DOI: 10.1093/humrep/deaa226] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 07/19/2020] [Indexed: 12/13/2022] Open
Abstract
STUDY QUESTION Does the freeze-all strategy in high-responders increase pregnancy rates and improve safety outcomes when compared with GnRH agonist triggering followed by low-dose hCG intensified luteal support with a fresh embryo transfer? SUMMARY ANSWER Pregnancy rates after either fresh embryo transfer with intensified luteal phase support using low-dose hCG or the freeze-all strategy did not vary significantly; however, moderate-to-severe ovarian hyperstimulation syndrome (OHSS) occurred more frequently in the women who attempted a fresh embryo transfer. WHAT IS KNOWN ALREADY Two strategies following GnRH agonist triggering (the freeze-all approach and a fresh embryo transfer attempt using a low-dose of hCG for intensified luteal phase support) are safer alternatives when compared with conventional hCG triggering with similar pregnancy outcomes. However, these two strategies have never been compared head-to-head in an unrestricted predicted hyper-responder population. STUDY DESIGN, SIZE, DURATION This study included women with an excessive response to ovarian stimulation (≥18 follicles measuring ≥11 mm) undergoing IVF/ICSI in a GnRH antagonist suppressed cycle between 2014 and 2017. Our primary outcome was clinical pregnancy at 7 weeks after the first embryo transfer. Secondary outcomes included live birth and the development of moderate-to-severe OHSS. PARTICIPANTS/MATERIALS, SETTING, METHODS Following GnRH agonist triggering, women were randomized either to cryopreserve all good-quality embryos followed by a frozen embryo transfer in an subsequent artificial cycle or to perform a fresh embryo transfer with intensified luteal phase support (1500 IU hCG on the day of oocyte retrieval, plus oral estradiol 2 mg two times a day, plus 200 mg of micronized vaginal progesterone three times a day). MAIN RESULTS AND THE ROLE OF CHANCE A total of 212 patients (106 in each arm) were recruited in the study, with three patients (one in the fresh embryo transfer group and two in the freeze-all group) later withdrawing their consent to participate in the study. One patient in the freeze-all group became pregnant naturally (clinical pregnancy diagnosed 38 days after randomization) prior to the first frozen embryo transfer. The study arms did not vary significantly in terms of the number of oocytes retrieved and embryos produced/transferred. The intention to treat clinical pregnancy and live birth rates (with the latter excluding four cases lost to follow-up: one in the fresh transfer and three in the freeze-all arms, respectively) after the first embryo transfer did not vary significantly among the fresh embryo transfer and freeze-all study arms: 51/105 (48.6%) versus 57/104 (54.8%) and 41/104 (39.4%) versus 42/101 (41.6%), respectively (relative risk for clinical pregnancy 1.13, 95% CI 0.87-1.47; P = 0.41). However, moderate-to-severe OHSS occurred solely in the group that received low-dose hCG (9/105, 8.6%, 95% CI 3.2% to 13.9% vs 0/104, 95% CI 0 to 3.7, P < 0.01). LIMITATIONS, REASONS FOR CAUTION The sample size calculation was based on a 19% absolute difference in terms of clinical pregnancy rates, therefore smaller differences, as observed in the trial, cannot be reliably excluded as non-significant. WIDER IMPLICATIONS OF THE FINDINGS This study offers the first comparative analysis of two common strategies applied to women performing IVF/ICSI with a high risk to develop OHSS. While pregnancy rates did not vary significantly, a fresh embryo transfer with intensified luteal phase support may still not avoid the risk of moderate-to-severe OHSS and serious consideration should be made before recommending it as a routine first-line treatment. Future trials may allow us to confirm these findings. STUDY FUNDING/COMPETING INTEREST(S) The authors have no conflicts of interest to disclose. No external funding was obtained for this study. TRIAL REGISTRATION NUMBER ClinicalTrials.gov identifier NCT02148393. TRIAL REGISTRATION DATE 28 May 2014. DATE OF FIRST PATIENT’S ENROLMENT 30 May 2014.
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Affiliation(s)
- Samuel Santos-Ribeiro
- IVIRMA Lisboa, Avenida Infante Dom Henrique 333 H 1-9, Lisbon, Portugal.,Department of Obstetrics and Gynecology, Faculty of Medicine, University of Lisbon, Lisboa, Portugal.,Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Shari Mackens
- Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | | | - Annalisa Racca
- Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Nikolaos P Polyzos
- Department of Obstetrics, Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain.,Department of Surgical and Clinical Science, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium.,Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Lisbet Van Landuyt
- Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Panagiotis Drakopoulos
- Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium.,Department of Surgical and Clinical Science, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Michel de Vos
- Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Herman Tournaye
- Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Christophe Blockeel
- Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium.,Department of Obstetrics and Gynaecology, School of Medicine, University of Zagreb, Zagreb, Croatia
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13
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Haas J, Bassil R, Samara N, Zilberberg E, Mehta C, Orvieto R, Casper RF. GnRH agonist and hCG (dual trigger) versus hCG trigger for final follicular maturation: a double-blinded, randomized controlled study. Hum Reprod 2021; 35:1648-1654. [PMID: 32563188 DOI: 10.1093/humrep/deaa107] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 04/18/2020] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTION Does co-administration of GnRH agonist and Human chorionic gonadotropin (hCG; dual trigger) in IVF cycles improve the number of mature oocytes and pregnancy outcome compared to hCG alone? SUMMARY ANSWER Using the dual trigger for final follicular maturation increases the number of oocytes, mature oocytes and number of blastocysts (total and top-quality) compared to triggering with hCG alone. WHAT IS KNOWN ALREADY hCG is used at the end of controlled ovarian hyperstimulation as a surrogate LH surge to induce final oocyte maturation. Recently, based on retrospective studies, the co-administration of GnRH agonist and hCG for final oocyte maturation (dual trigger) has been suggested to improve IVF outcome and pregnancy rates. STUDY DESIGN, SIZE, DURATION A single center, randomized controlled, double-blinded clinical trial between May 2016 and June 2018 analyzed by intention to treat (ITT). PARTICIPANTS/MATERIALS, SETTINGS, METHODS One hundred and fifty-five normal responder patients were randomized either to receive hCG or dual trigger for final oocyte maturation. Data on patients age, BMI, AMH, number of oocytes retrieved, number of metaphase 2 (MII) oocytes, zygotes and blastocysts, clinical pregnancy rate and live birth rate were assessed and compared between the dual trigger group and the hCG group. We performed a planned interim analysis after the recruitment of 50% of the patients. Based on the totality of outcomes at the interim analysis we decided to discontinue further recruitment. MAIN RESULTS AND THE ROLE OF CHANCE One hundred and fifty-five patients were included in the study. The age (36 years versus 35.3 years P = NS), BMI (24 kg/m2 versus 23.7 kg/m2) and the AMH (20.1 pmol/l versus 22.4 pmol/l) were comparable between the two groups. Based on ITT analysis, the number of eggs retrieved (11.1 versus 13.4, P = 0.002), the MII oocytes (8.6 versus 10.3, P = 0.009), total number of blastocysts (2.9 versus 3.9, P = 0.01) and top-quality blastocysts transferred (44.7% versus 64.9%; P = 0.003) were significantly higher in the dual trigger group compared to the hCG group. The clinical pregnancy rate (24.3% versus 46.1%, OR 2.65 (1.43-1.93), P = 0.009) and the live birth rate per transfer (22% versus 36.2%, OR= 1.98 (1.05-3.75), P = 0.03) were significantly higher in the dual trigger group compared to the hCG group. LIMITATIONS, REASONS FOR CAUTION None. WIDER IMPLICATIONS OF THE FINDINGS The enhanced response observed with the dual trigger might lead to better IVF outcomes were it used more widely. STUDY FUNDING/COMPETING INTEREST(S) The study was funded by TRIO Fertility. There are no conflicts of interest to declare. TRIAL REGISTRATION NUMBER ClinicalTrials.gov identifier: NCT02703584. DATE OF TRIAL REGISTRATION March 2016. DATE OF FIRST PATIENT'S ENROLLMENT May 2016.
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Affiliation(s)
- J Haas
- TRIO Fertility, Toronto, ON, Canada.,IVF Unit, Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - R Bassil
- TRIO Fertility, Toronto, ON, Canada
| | - N Samara
- TRIO Fertility, Toronto, ON, Canada
| | - E Zilberberg
- TRIO Fertility, Toronto, ON, Canada.,IVF Unit, Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - C Mehta
- TRIO Fertility, Toronto, ON, Canada
| | - R Orvieto
- IVF Unit, Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - R F Casper
- TRIO Fertility, Toronto, ON, Canada.,Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada.,Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
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14
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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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15
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Oocyte competence is independent of the ovulation trigger adopted: a large observational study in a setting that entails vitrified-warmed single euploid blastocyst transfer. J Assist Reprod Genet 2021; 38:1419-1427. [PMID: 33661465 DOI: 10.1007/s10815-021-02124-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/21/2021] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To assess whether the GnRH-agonist or urinary-hCG ovulation triggers affect oocyte competence in a setting entailing vitrified-warmed euploid blastocyst transfer. METHODS Observational study (April 2013-July 2018) including 2104 patients (1015 and 1089 in the GnRH-a and u-hCG group, respectively) collecting ≥1 cumulus-oocyte-complex (COC) and undergoing ICSI with ejaculated sperm, blastocyst culture, trophectoderm biopsy, comprehensive-chromosome-testing, and vitrified-warmed transfers at a private clinic. The primary outcome measure was the euploid-blastocyst-rate per inseminated oocytes. The secondary outcome measure was the maturation-rate per COCs. Also, the live-birth-rate (LBR) per transfer and the cumulative-live-birth-delivery-rate (CLBdR) among completed cycles were investigated. All data were adjusted for confounders. RESULTS The generalized-linear-model adjusted for maternal age highlighted no difference in the mean euploid-blastocyst-rate per inseminated oocytes in either group. The LBR per transfer was similar: 44% (n=403/915) and 46% (n=280/608) in GnRH-a and hCG, respectively. On the other hand, a difference was reported regarding the CLBdR per oocyte retrieval among completed cycles, with 42% (n=374/898) and 25% (n=258/1034) in the GnRh-a and u-hCG groups, respectively. Nevertheless, this variance was due to a lower maternal age and higher number of inseminated oocytes in the GnRH-a group, and not imputable to the ovulation trigger itself (multivariate-OR=1.3, 95%CI: 0.9-1.6, adjusted p-value=0.1). CONCLUSION GnRH-a trigger is a valid alternative to u-hCG in freeze-all cycles, not only for patients at high risk for OHSS. Such strategy might increase the safety and flexibility of controlled-ovarian-stimulation with no impact on oocyte competence and IVF efficacy.
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16
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Wu HM, Chang HM, Leung PCK. Gonadotropin-releasing hormone analogs: Mechanisms of action and clinical applications in female reproduction. Front Neuroendocrinol 2021; 60:100876. [PMID: 33045257 DOI: 10.1016/j.yfrne.2020.100876] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/23/2020] [Accepted: 10/04/2020] [Indexed: 12/15/2022]
Abstract
Extra-hypothalamic GnRH and extra-pituitary GnRH receptors exist in multiple human reproductive tissues, including the ovary, endometrium and myometrium. Recently, new analogs (agonists and antagonists) and modes of GnRH have been developed for clinical application during controlled ovarian hyperstimulation for assisted reproductive technology (ART). Additionally, the analogs and upstream regulators of GnRH suppress gonadotropin secretion and regulate the functions of the reproductive axis. GnRH signaling is primarily involved in the direct control of female reproduction. The cellular mechanisms and action of the GnRH/GnRH receptor system have been clinically applied for the treatment of reproductive disorders and have widely been introduced in ART. New GnRH analogs, such as long-acting GnRH analogs and oral nonpeptide GnRH antagonists, are being continuously developed for clinical application. The identification of the upstream regulators of GnRH, such as kisspeptin and neurokinin B, provides promising potential to develop these upstream regulator-related analogs to control the hypothalamus-pituitary-ovarian axis.
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Affiliation(s)
- Hsien-Ming Wu
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University School of Medicine, Taoyuan 333, Taiwan, ROC
| | - Hsun-Ming Chang
- Department of Obstetrics and Gynaecology, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia V6H 3V5, Canada
| | - Peter C K Leung
- Department of Obstetrics and Gynaecology, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia V6H 3V5, Canada.
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17
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Martazanova B, Mishieva N, Vtorushina V, Vedikhina I, Levkov L, Korneeva I, Kirillova A, Krechetova L, Abubakirov A, Sukhikh GT. Angiogenic cytokine and interleukin 8 levels in early luteal phase after triggering ovulation with gonadotropin-releasing hormone agonist in high-responder patients. Am J Reprod Immunol 2020; 85:e13381. [PMID: 33247970 DOI: 10.1111/aji.13381] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 10/17/2020] [Accepted: 11/23/2020] [Indexed: 12/19/2022] Open
Abstract
PROBLEM Interleukin 8 (IL-8), vascular endothelial growth factor A (VEGFA), its receptors 1 (VEGFR1) and 2 (VEGFR2) are associated with ovarian hyperstimulation syndrome (OHSS) pathophysiological mechanisms. The aim of this study was to evaluate the concentrations of these cytokines depending on the way of ovulation triggering. METHOD OF STUDY A total of 51 high-responder patients underwent IVF program and received gonadotropin-releasing hormone agonists (GnRHa) trigger + 1500 IU human chorionic gonadotropin (hCG) support on the oocyte pick-up (OPU) day (group I), dual trigger (GnRHa + 1500 IU hCG; group II), or hCG trigger 10,000 IU (group III) for the final oocyte maturation. The concentrations of cytokines were evaluated in serum by the enzyme-linked immunosorbent assay kit. RESULT(S) VEGFR2 levels were significantly lower in groups I and II than in group III in serum on the OPU (I vs. III, p = .0456; II vs. III, p = .0122) and OPU + 5 day (I vs. III, p = .0004; II vs. III, p = .0082). VEGFA levels were lower in group I than in group III (p = .0298) on the OPU day, however, were similar in all groups on the OPU + 5 day. CONCLUSION(S) A small dose of hCG elicits similar concentrations of VEGFA to a full dose of hCG; however, GnRHa triggering reduces the concentrations of VEGFR2, which could lead to the OHSS prevention.
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Affiliation(s)
- Bella Martazanova
- FSBI National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Healthcare of Russian Federation, Moscow, Russia
| | - Nona Mishieva
- FSBI National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Healthcare of Russian Federation, Moscow, Russia
| | - Valentina Vtorushina
- FSBI National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Healthcare of Russian Federation, Moscow, Russia
| | - Irina Vedikhina
- FSBI National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Healthcare of Russian Federation, Moscow, Russia
| | - Lev Levkov
- FSBI National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Healthcare of Russian Federation, Moscow, Russia
| | - Irina Korneeva
- FSBI National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Healthcare of Russian Federation, Moscow, Russia
| | - Anastasia Kirillova
- FSBI National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Healthcare of Russian Federation, Moscow, Russia
| | - Lubov Krechetova
- FSBI National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Healthcare of Russian Federation, Moscow, Russia
| | - Aydar Abubakirov
- FSBI National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Healthcare of Russian Federation, Moscow, Russia
| | - Gennady T Sukhikh
- FSBI National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Healthcare of Russian Federation, Moscow, Russia
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18
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Oron G, Sapir O, Wertheimer A, Shufaro Y, Bar-Gil R, Margalit T, Shlush E, Ben-Haroush A. A matched propensity score study of embryo morphokinetics following gonadotropin-releasing hormone agonist versus human chorionic gonadotropin trigger. J Assist Reprod Genet 2020; 37:2777-2782. [PMID: 32980940 DOI: 10.1007/s10815-020-01953-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 09/17/2020] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To compare morphokinetic parameters and quality of embryos derived from GnRH antagonist ICSI cycles triggered either with GnRH agonist or standard hCG between matched groups of patients. METHODS Morphokinetic parameters of embryos derived from matched first GnRH antagonist ICSI cycles triggered by GnRH agonist or standard hCG between 2013 and 2016 were compared. Matching was performed for maternal age, peak estradiol levels, and number of oocytes retrieved. Outcome measures were: time to pronucleus fading (tPNf), cleavage timings (t2-t8), synchrony of the second and third cycles (S2 and S3), duration of the second and third cycle (CC2 and CC3), optimal cell cycle division parameters, and known implantation data (KID) scoring for embryo quality. Multivariate linear and logistic regression analyses were performed for confounding factors. RESULTS We analyzed 824 embryos from 84 GnRH agonist trigger cycles and 746 embryos from 84 matched hCG trigger cycles. Embryos derived from the cycles triggered with hCG triggering cleaved faster than those deriving from GnRH agonist trigger. The differences were significant throughout most stages of embryo development (t3-t6), and a shorter second cell cycle duration of the hCG trigger embryos was observed. There was no difference in synchrony of the second and third cell cycles and the optimal cell cycle division parameters between the two groups, but there was a higher percentage of embryos without multinucleation in the hCG trigger group (27.8% vs. 21.6%, p < 0.001). CONCLUSION The type of trigger in matched antagonist ICSI cycles was found to affect early embryo cleavage times but not embryo quality.
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Affiliation(s)
- Galia Oron
- Infertility and IVF Unit, Helen Schneider Hospital for Women, Rabin Medical Center, Beilinson Hospital, 4941492, Petah Tikva, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Onit Sapir
- Infertility and IVF Unit, Helen Schneider Hospital for Women, Rabin Medical Center, Beilinson Hospital, 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avital Wertheimer
- Infertility and IVF Unit, Helen Schneider Hospital for Women, Rabin Medical Center, Beilinson Hospital, 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoel Shufaro
- Infertility and IVF Unit, Helen Schneider Hospital for Women, Rabin Medical Center, Beilinson Hospital, 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Roni Bar-Gil
- Infertility and IVF Unit, Helen Schneider Hospital for Women, Rabin Medical Center, Beilinson Hospital, 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tamar Margalit
- Infertility and IVF Unit, Helen Schneider Hospital for Women, Rabin Medical Center, Beilinson Hospital, 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ekaterina Shlush
- Infertility and IVF Unit, Helen Schneider Hospital for Women, Rabin Medical Center, Beilinson Hospital, 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avi Ben-Haroush
- Infertility and IVF Unit, Helen Schneider Hospital for Women, Rabin Medical Center, Beilinson Hospital, 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Progesterone use in assisted reproductive technology. Best Pract Res Clin Obstet Gynaecol 2020; 69:74-84. [PMID: 32616441 DOI: 10.1016/j.bpobgyn.2020.05.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/06/2020] [Accepted: 05/06/2020] [Indexed: 11/21/2022]
Abstract
Progesterone is the main hormone in the luteal phase. It plays a key role in preparing the uterus for a possible pregnancy, and in maintaining it after it has occurred. In assisted reproduction treatments, there is usually a luteal phase deficiency, so it is necessary to supplement this critical phase to obtain the best results, not only of implantation but also of ongoing pregnancy. Among all the available options, exogenously administered progestogens are the most used, as they have proven their efficacy and safety. This review will address the most relevant aspects of luteal phase support with progesterone in the different scenarios an embryo transfer can be performed, such as the stimulated cycle, the artificial cycle, or the natural cycle. Although there is no evidence of the perfect protocol for all patients, recent studies point to the need of individualizing luteal phase support according to the needs of each patient.
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20
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Yılmaz N, Ceran MU, Ugurlu EN, Gülerman HC, Engin Ustun Y. GnRH agonist versus HCG triggering in different IVF/ICSI cycles of same patients: a retrospective study. J OBSTET GYNAECOL 2019; 40:837-842. [PMID: 31791167 DOI: 10.1080/01443615.2019.1674262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The aim of this study was to assess Gonadotropin Releasing Hormone agonist (GnRHa) trigger results of fresh in vitro fertilisation (IVF), Intracytoplasmic Sperm Injection (ICSI) cycles in high-responder patients. Thirty-six high-responder patients, undergoing GnRH antagonist protocol combined with GnRHa trigger for final oocyte maturation, were included. All cycles were autologous fresh transfer cycles. Fifteen of 36 patients had previous IVF/ICSI cycles triggered with human chorionic gonadotropin (hCG) and both cycles of these patients were compared. The mean fertilisation rate, blastocyst development and clinical pregnancy rates were 67%, 44.4% and 44.4%, respectively. The hCG and GnRHa trigger cycles of the same patients were compared as two groups (n: 15). 2PN oocyte counts were significantly higher in agonist trigger cycles (p .048). There were no differences in terms of M2 oocyte count and fertilisation rate. The blastocyst formation and clinical pregnancy rates for hCG and GnRHa trigger cycles were 33.3-66.7% and 13.3-46.7%, respectively. These results were found to be 2-fold and 3.5-fold higher, but not statistically significant. GnRHa trigger in combination with LPS is a good option for final oocyte maturation due to its good pregnancy outcomes and virtually eliminating OHSS risks.IMPACT STATEMENTWhat is already known on this subject? Gonadotrophin releasing hormone agonist (GnRHa) trigger is effective in the induction of oocyte maturation and prevention of Ovarian Hyperstimulation Syndrome (OHSS) on IVF cycles using antagonist protocol.What do the results of this study add? The main strength of this study is the comparison of different triggers in different cycles of the same patients. GnRHa trigger in combination with Luteal Phase Support (LPS) is a good option for final oocyte maturation due to its good pregnancy outcomes and virtually eliminating OHSS risks.What are the implications of these findings for clinical practice and/or further research? We suppose that GnRHa trigger combined with modified LPS is clinically more successful than Human Chorionic Gonadotropin (hCG) in regard to OHSS prevention and reproductive outcomes on fresh IVF/ICSI cycles. More extensive studies are needed to draw firm conclusions.
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Affiliation(s)
- Nafiye Yılmaz
- Department of Reproductive Endocrinology, Health Science University Zekai Tahir Burak Women's Health, Education and Research Hospital, Ankara, Turkey
| | - Mehmet Ufuk Ceran
- Department of Gynecology and Obstetrics, Baskent University School of Medicine, Konya Medical and Research Center, Ankara, Turkey
| | - Evin Nil Ugurlu
- Department of Gynecology and Obstetrics, Medical Park Health Group, Mersin, Turkey
| | - Hacer Cavidan Gülerman
- Department of Reproductive Endocrinology, Health Science University Zekai Tahir Burak Women's Health, Education and Research Hospital, Ankara, Turkey
| | - Yaprak Engin Ustun
- Department of Reproductive Endocrinology, Health Science University Zekai Tahir Burak Women's Health, Education and Research Hospital, Ankara, Turkey
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Chau LTM, Tu DK, Lehert P, Dung DV, Thanh LQ, Tuan VM. Clinical pregnancy following GnRH agonist administration in the luteal phase of fresh or frozen assisted reproductive technology (ART) cycles: Systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol X 2019; 3:100046. [PMID: 31403130 PMCID: PMC6687475 DOI: 10.1016/j.eurox.2019.100046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 04/25/2019] [Accepted: 05/10/2019] [Indexed: 11/19/2022] Open
Abstract
Objective(s) To study if the GnRH agonist administration in luteal phase improves clinical pregnancy rate of fresh and frozen embryo transfer. Also, this meta-analysis compares the treatment effect of luteal GnRH agonist administration between long agonist and antagonist protocols of fresh cycles, and between two types of treatment: fresh and frozen embryo transfers. Study design Systematic review and meta-analysis (registration number CRD42017059152) Results For the overall 20 studies (5497 patients), clinical pregnancy rate significantly increased in group of GnRH agonist administration compared to control group (RR 1.24, 95% CI 1.14–1.34, p < 0.0001). Regarding the treatment effect of luteal GnRH agonist administration between long agonist and antagonist protocol fresh cycles, no significant difference was observed (RR = 1.28, 95% CI 0.98–1.67, p = 0.07). Also, in comparison between fresh and frozen embryo transfer, similar effect of GnRH agonist administration was found (RR = 0.93, 95% CI 0.74–1.16, p = 0.49). Conclusion(s) There is evidence that GnRH agonist administration in luteal phase improve clinical pregnancy rate in both fresh and frozen cycles. Within fresh cycles, no significant difference of clinical pregnancy rate is found between two protocols. In frozen cycles, the effect of GnRH agonist administration in enhancing clinical pregnancy rate is similar to fresh cycles.
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Affiliation(s)
- Le Thi Minh Chau
- Department of Infertility, Tu Du hospital, Vietnam
- Corresponding author at: Tu Du hospital.
| | | | - Philippe Lehert
- Faculty of Medicine, the University of Melbourne, Australia
- Faculty of Economics, UCL Mons, Louvain, Belgium
| | - Do Van Dung
- University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
| | | | - Vo Minh Tuan
- University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
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22
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Friedler S, Grin L. Luteal phase support with GnRH agonist does not eliminate the risk for ovarian hyperstimulation syndrome. Gynecol Endocrinol 2019; 35:368-369. [PMID: 30614333 DOI: 10.1080/09513590.2018.1548591] [Citation(s) in RCA: 5] [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: 10/27/2022] Open
Abstract
This study aims to report a case of early, severe ovarian hyperstimulation syndrome (OHSS) following GnRH agonist trigger for final oocyte maturation despite luteal support with a GnRH agonist. Contrary to the claim that luteal support using a GnRH agonist eliminates the risk for OHSS in high-risk patients, this report alerts practitioners to the risk of severe OHSS development despite GnRH agonist luteal support in patients receiving GnRH antagonist protocol with GnRH agonist triggering and cautions the practitioners to consider other measures of OHSS prevention.
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Affiliation(s)
- Shevach Friedler
- a Infertility and IVF Unit , Barzilai University Medical Center , Ashkelon , Israel
- b Faculty of Health Sciences , Ben Gurion University of the Negev , Beer-Sheva , Israel
| | - Leonti Grin
- a Infertility and IVF Unit , Barzilai University Medical Center , Ashkelon , Israel
- b Faculty of Health Sciences , Ben Gurion University of the Negev , Beer-Sheva , Israel
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23
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Elgindy EA, Sibai H, Mostafa MI, Gibreel A, Darwish E, Maghraby H. Towards an optimal luteal support modality in agonist triggered cycles: a randomized clinical trial. Hum Reprod 2019; 33:1079-1086. [PMID: 29562260 DOI: 10.1093/humrep/dey054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 02/22/2018] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTION In ICSI patients with high risk of ovarian hyperstimulation syndrome (OHSS), are antagonist cycles triggered by gonadotropin releasing hormone (GNRH) agonist with a specialized luteal support regimen associated with comparable ongoing pregnancy rate (OPR) and less OHSS than those triggered by hCG? SUMMARY ANSWER In antagonist ICSI cycles, GnRH agonist triggering with a specialized luteal support regimen is associated with comparable OPR to those triggered by hCG but may be less likely to be associated with OHSS. WHAT IS KNOWN ALREADY In IVF/ICSI protocols, exogenous hCG was used for years as a substitute of the endogenous LH surge. However, because of its longer half life, hCG is associated with more risk of OHSS, especially in high risk women. For this reason, GnRH agonist triggering was introduced. There is, however, no consensus on the best protocol for luteal support on agonist triggered cycles. STUDY DESIGN, SIZE, DURATION Randomized controlled open label trial including 190 participants recruited from June 2015 to March 2016 in a private fertility center. Participants were divided into 2 equal groups; GnRH agonist trigger and hCG trigger. Randomization was done using identical sealed envelope technique. PARTICIPANTS/MATERIALS, SETTING, METHODS One hundred ninety women, predicted to have high response, were randomized on the day of final oocyte maturation into two equal groups: group (A), GnRH agonist trigger followed by specialized regimen (1500 IU hCG) at time of oocyte retrieval plus oral estradiol and intramuscular progesterone during luteal phase; and group (B), 5000 IU of hCG with luteal support (oral estradiol and vaginal progesterone). MAIN RESULTS AND THE ROLE OF CHANCE The 2 groups were comparable in baseline characteristics. OPR per randomized patient was comparable in the 2 groups {49/95 (51.6%) in group A, and 50/95 (52.6%) in group B ((P = 0.88); RR = 0.980, 95% CI: 0.75-1.29)}. Considerable (moderate + severe) OHSS was higher in group B (13/95 [14%] versus 5/95 [5%] P = 0.047; uncorrected Chi-square test). Upon performing multivariate regression analysis for predicting OHSS, number of follicles ≥11 mm on trigger day was the only independent predictor (P = 0.0004). LIMITATIONS, REASONS FOR CAUTION Strict selection criteria limit generalization of results. The study was powered for pregnancy rate not OHSS, so that the strength of evidence on OHSS prediction is weak. WIDER IMPLICATIONS OF THE FINDINGS We recommend the use of GnRH agonist plus the specialized luteal phase support in high responders with high risk of OHSS undergoing IVF/ICSI cycles. This protocol achieved a similar ongoing pregnancy to hCG triggering and may be less likely to result in moderate to severe OHSS. STUDY FUNDING/COMPETING INTEREST(S) None. TRIAL REGISTRATION NUMBER PACTR 201506001132105. TRIAL REGISTRATION DATE 24/6/2015. DATE OF FIRST PATIENT’S ENROLLMENT 26/6/2015.
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Affiliation(s)
- E A Elgindy
- Obstetrics and Gynecology Department, Zagazig University, Zagazig, Sharkia 44511, Egypt
| | - H Sibai
- Obstetrics and Gynecology Department, Zagazig University, Zagazig, Sharkia 44511, Egypt
| | - M I Mostafa
- Obstetrics and Gynecology Department, Kasr Al Ainy School of Medicine, Cairo University, El Saraya St., Cairo 11562, Egypt
| | - A Gibreel
- Obstetrics and Gynecology Department, Mansoura University, Mansoura, Dakahlia 35516, Egypt
| | - E Darwish
- Obstetrics and Gynecology Department, Alexandria University, Alexandria 21523, Egypt
| | - H Maghraby
- Obstetrics and Gynecology Department, Alexandria University, Alexandria 21523, Egypt
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24
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Engmann LL, Maslow BS, Kaye LA, Griffin DW, DiLuigi AJ, Schmidt DW, Grow DR, Nulsen JC, Benadiva CA. Low dose human chorionic gonadotropin administration at the time of gonadotropin releasing-hormone agonist trigger versus 35 h later in women at high risk of developing ovarian hyperstimulation syndrome - a prospective randomized double-blind clinical trial. J Ovarian Res 2019; 12:8. [PMID: 30684970 PMCID: PMC6347742 DOI: 10.1186/s13048-019-0483-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 01/17/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ovarian hyperstimulation syndrome remains a serious complication during in vitro fertilization cycles if high dose human chorionic gonadotropin (hCG) is used to trigger ovulation in high responder patients. Though much of this risk is mitigated with trigger using gonadotropin releasing-hormone (GnRH) agonist alone, it may result in lower birth rates. GnRH-agonist trigger and adjuvant low dose hCG has been proposed to improve birth rates, but timing of this hCG support to corpus luteum function has never been fully described. In this randomized, prospective trial, we explore differences in live birth rates and incidence of ovarian hyperstimulation syndrome (OHSS) in high-responder patients undergoing in vitro fertilization (IVF) receiving low dose hCG at the time of GnRH-agonist (dual trigger) or hCG adjuvant at the time of oocyte retrieval. Does the timing of hCG support make a difference? RESULTS Thirty-four subjects high-responder patients were randomized to receive low-dose hCG at the time of GnRH-agonist trigger (Group 1) and 37 received low-dose hCG at the time of oocyte retrieval (Group 2). There were no differences in the baseline characteristics and outcome of ovarian stimulation between the two groups. There were no differences in the live birth rates between Group 1 and Group 2 by intention-to-treat (14/34, 41.2% versus 21/37, 56.8%, p = 0.19) or per-protocol (14/26, 53.8% versus 19/31, 61.3%, p = 0.57) analyses. There was a slightly higher incidence of OHSS in Group 2 compared to Group 1 although the difference was not statistically significant (3/31, 9.7% versus 1/26, 3.8%). All the cases of OHSS in Group 2 were moderate while the one case of OHSS in Group 1 was mild. CONCLUSIONS For high responder patients receiving GnRH-agonist trigger, low dose hCG supplementation allowed high pregnancy rates after fresh embryo transfer, regardless of whether it was given at the time of trigger or at oocyte retrieval. Dual trigger may be preferable to reduce the risk of OHSS.
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Affiliation(s)
- L L Engmann
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Center for Advanced Reproductive Services, University of Connecticut School of Medicine, Farmington, CT, 06030, USA. .,Center for Advanced Reproductive Services, 2 Batterson Park Road, Farmington, CT, 06032, USA.
| | - B S Maslow
- Gold Coast IVF, Woodbury, NY, 11797, USA
| | - L A Kaye
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Center for Advanced Reproductive Services, University of Connecticut School of Medicine, Farmington, CT, 06030, USA
| | - D W Griffin
- Boston IVF at the Women's Hospital, Newburgh, IN, 47630, USA
| | - A J DiLuigi
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Center for Advanced Reproductive Services, University of Connecticut School of Medicine, Farmington, CT, 06030, USA.,Center for Advanced Reproductive Services, 2 Batterson Park Road, Farmington, CT, 06032, USA
| | - D W Schmidt
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Center for Advanced Reproductive Services, University of Connecticut School of Medicine, Farmington, CT, 06030, USA.,Center for Advanced Reproductive Services, 2 Batterson Park Road, Farmington, CT, 06032, USA
| | - D R Grow
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Center for Advanced Reproductive Services, University of Connecticut School of Medicine, Farmington, CT, 06030, USA.,Center for Advanced Reproductive Services, 2 Batterson Park Road, Farmington, CT, 06032, USA
| | - J C Nulsen
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Center for Advanced Reproductive Services, University of Connecticut School of Medicine, Farmington, CT, 06030, USA.,Center for Advanced Reproductive Services, 2 Batterson Park Road, Farmington, CT, 06032, USA
| | - C A Benadiva
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Center for Advanced Reproductive Services, University of Connecticut School of Medicine, Farmington, CT, 06030, USA.,Center for Advanced Reproductive Services, 2 Batterson Park Road, Farmington, CT, 06032, USA
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25
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Chambers AE, Fairbairn C, Gaudoin M, Mills W, Woo I, Pandian R, Stanczyk FZ, Chung K, Banerjee S. Soluble LH-HCG receptor and oestradiol as predictors of pregnancy and live birth in IVF. Reprod Biomed Online 2018; 38:159-168. [PMID: 30598377 DOI: 10.1016/j.rbmo.2018.11.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 10/23/2018] [Accepted: 11/01/2018] [Indexed: 01/03/2023]
Abstract
RESEARCH QUESTION Circulating soluble LH-HCG receptor (sLHCGR) is a first-trimester marker for screening pregnancy pathologies and predicts premature or multiple births before fertility treatment. Oestradiol per oocyte at ovulation induction predicts IVF treatment outcomes. We asked whether sLHCGR levels are stable during fertility treatment and whether, alone or with oestradiol, they could improve prediction of fertility treatment outcomes. DESIGN Serum sLHCGR, anti-Müllerian hormone [AMH] and oestradiol were measured in patients undergoing IVF. Antral follicle count before ovarian stimulation and oocyte yield were used to establish sLHCGR- oocyte ratio (SOR), sLHCGR- antral follicle ratio (SAR), oestradiol at trigger per oocyte (oestradiol-oocyte ratio [EOR]) and oestradiol at trigger per antral follicle (oestradiol-antral follicle ratio [EAR]). RESULTS The relatively stable sLHCGR was negatively related to AMH when oocyte yield was high. The sLHCGR levels were proportional (r = 0.49) to oestradiol at early cycle (day-3). Pregnancy and live birth were highest at low sLHCGR (≤1.0 pmol/ml) and SOR (≤ 0.1 pmol/ml/oocyte). A total of 86-89% of live births in IVF treatment were within the cut-off parameters of SAR and SOR (0.5 pmol/ml) and EAR and EOR (380 pg/ml). For failed pregnancy, age, SOR and EOR together had positive and negative predictive values of 0.841 and 0.703, respectively. CONCLUSIONS sLHCGR levels are negatively related to AMH when oocyte yield is high. High early cycle sLHCGR is associated with elevated day-3 oestradiol. Low sLHCGR and SOR are indicators of increased clinical pregnancy and live birth rates. Patient age and SOR, combined with EOR, might improve prediction of IVF treatment outcomes.
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Affiliation(s)
| | - Craig Fairbairn
- GCRM Glasgow Centre For Reproductive Medicine, 21 Fifty Pitches Way, Cardonald Business Park, Glasgow, G51 4FD, UK
| | - Marco Gaudoin
- GCRM Glasgow Centre For Reproductive Medicine, 21 Fifty Pitches Way, Cardonald Business Park, Glasgow, G51 4FD, UK
| | - Walter Mills
- Origin Biomarkers, Biocity Scotland, B'oness Road, Newhouse, Lanarkshire ML1 5UH, UK
| | - Irene Woo
- Division of Reproductive Endocrinology and Infertility, University of Southern California, Keck School of Medicine, 1127 Wilshire Blvd., Los Angeles California, CA 90017, USA
| | - Raj Pandian
- Pan Laboratories, 15375 Barranca Parkway, Irvine California, USA
| | - Frank Z Stanczyk
- Division of Reproductive Endocrinology and Infertility, University of Southern California, Keck School of Medicine, 1127 Wilshire Blvd., Los Angeles California, CA 90017, USA
| | - Karine Chung
- Division of Reproductive Endocrinology and Infertility, University of Southern California, Keck School of Medicine, 1127 Wilshire Blvd., Los Angeles California, CA 90017, USA
| | - Subhasis Banerjee
- Origin Biomarkers, Biocity Scotland, B'oness Road, Newhouse, Lanarkshire ML1 5UH, UK
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Ortega I, García-Velasco JA, Pellicer A. Ovarian manipulation in ART: going beyond physiological standards to provide best clinical outcomes. J Assist Reprod Genet 2018; 35:1751-1762. [PMID: 30056596 DOI: 10.1007/s10815-018-1258-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 07/03/2018] [Indexed: 12/11/2022] Open
Abstract
Current knowledge on ovarian physiology has challenged the traditional concept of folliculogenesis, creating the basis for novel ovarian stimulation protocols in assisted reproduction technology. The purpose of this review was to evaluate the efficacy of novel clinical interventions that could aid clinicians in individualizing their protocols to patients' characteristics and personal situations. We conducted a literature review of the available evidence on new approaches for ovarian stimulation from both retrospective and prospective studies in the PubMed database. Here, we present some of the most important interventions, including follicle growth in the gonadotropin-independent and dependent stage, manipulation of estradiol production throughout ovarian stimulation, control of mid-cycle gonadotropin surges, and luteal phase support after different stimulation protocols and trigger agents. The latest research on IVF has moved physicians away from the classical physiology, allowing the development of new strategies to decouple organ functions from the female reproductive system and challenging the traditional concept of IVF.
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Affiliation(s)
- Israel Ortega
- IVI-Madrid, Madrid, Spain. .,Instituto de Investigación Sanitaria La Fé, Valencia, Spain.
| | - Juan A García-Velasco
- IVI-Madrid, Madrid, Spain.,Instituto de Investigación Sanitaria La Fé, Valencia, Spain.,Rey Juan Carlos University, Madrid, Spain.,IdiPAZ, Madrid, Spain
| | - Antonio Pellicer
- Instituto de Investigación Sanitaria La Fé, Valencia, Spain.,Rey Juan Carlos University, Madrid, Spain.,IdiPAZ, Madrid, Spain.,IVI-Roma, Rome, Italy
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27
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Benadiva C, Engmann L. Luteal phase support after gonadotropin-releasing hormone agonist triggering: does it still matter? Fertil Steril 2018; 109:763-767. [DOI: 10.1016/j.fertnstert.2018.02.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 01/26/2018] [Accepted: 02/01/2018] [Indexed: 12/17/2022]
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Petersen JF, Andersen AN, Klein BM, Helmgaard L, Arce JC. Luteal phase progesterone and oestradiol after ovarian stimulation: relation to response and prediction of pregnancy. Reprod Biomed Online 2018; 36:427-434. [PMID: 29398418 DOI: 10.1016/j.rbmo.2017.12.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 12/20/2017] [Accepted: 12/20/2017] [Indexed: 11/29/2022]
Abstract
Research has focused on optimizing luteal phase support and endometrial receptivity in ovarian stimulation cycles. In this study, serial endocrine measurements were taken in 600 patients after a gonadotrophin-releasing hormone antagonist stimulation protocol. On the day of blastocyst transfer, serum progesterone and oestradiol were similar irrespective of a subsequent positive or negative pregnancy test (median 99 ng/ml versus 103 ng/ml for progesterone, respectively) or a subsequent live birth or pregnancy loss. Serum progesterone was significantly correlated to each ovarian response parameter (total number of follicles, number of oocytes retrieved and oestradiol concentration; r = 0.45, 0.57 and 0.54 respectively, all P < 0.0001). These correlations were consistent irrespective of clinical outcome. On the day of the pregnancy test, these correlations had vanished except in the live birth subgroup showing a weaker correlation (r = 0.22, 0.27 and 0.32 respectively, all P < 0.005). The lowest HCG and progesterone levels associated with live birth were 59.3 IU/l and 12.3 ng/ml, respectively. Fourteen out of 92 patients (15.2%) with pregnancy loss had normal HCG but low progesterone levels (above and below their respective 5th percentile), and miscarried before the end of the 7th week, when the luteal-placental shift occurs.
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Affiliation(s)
- Jesper Friis Petersen
- The Fertility Clinic, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100, Copenhagen, Denmark; Department of Obstetrics and Gynecology, North Zealand Copenhagen University Hospital, Dyrehavevej 29, DK-3400, Hilleroed, Denmark.
| | - Anders Nyboe Andersen
- The Fertility Clinic, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Bjarke Mirner Klein
- Global Biometrics, Ferring Pharmaceuticals A/S, Kay Fiskers Plads 11, DK-2300, Copenhagen S, Denmark
| | - Lisbeth Helmgaard
- Reproductive Health, Ferring Pharmaceuticals A/S, Kay Fiskers Plads 11, DK-2300, Copenhagen S, Denmark
| | - Joan-Carles Arce
- Ferring Pharmaceuticals Development, 100 Interpace Pkwy, Parsippany, NJ 07054, USA
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Deferred Frozen Embryo Transfer: What Benefits can be Expected from this Strategy in Patients with and without Endometriosis? JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2017. [DOI: 10.5301/jeppd.5000281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Progress with cryopreservation techniques have enabled development of the deferred frozen-thawed embryo transfer (DET) strategy as an alternative to relying on fresh embryo transfers. With DET, the entire embryo cohort is cryopreserved, and embryo transfer is then performed in a subsequent cycle that takes place separately from the controlled ovarian stimulation (COS). Initially developed to limit the risk of ovarian hyperstimulation syndrome that occurs with high responders, this strategy has been applied extensively with other populations in an effort to improve implantation rates. The assumption is that COS, which is essential for in vitro fertilization/intra cytoplasmic sperm injection (IVF/ICSI) procedures to obtain a multi-follicular development, could have a detrimental impact on the endometrium as a result of greatly elevated levels of steroids. It is currently not clear whether the DET strategy can be generally applied to all women requiring an IVF/ICSI procedure. The objectives of this literature review regarding DET, were hence: (i) to present the scientific background that contributed to extensive adoption of this technique, (ii) to detail the pregnancy outcomes and potential obstetric and neonatal consequences, (iii) to report on its ability to prevent risks induced by COS, and (iv) to propose indications for the DET strategy in clinical practice.
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30
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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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31
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Vuong TNL, Ho MT, Ha TQ, Jensen MB, Andersen CY, Humaidan P. Effect of GnRHa ovulation trigger dose on follicular fluid characteristics and granulosa cell gene expression profiles. J Assist Reprod Genet 2017; 34:471-478. [PMID: 28197932 DOI: 10.1007/s10815-017-0891-9] [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: 11/29/2016] [Accepted: 02/03/2017] [Indexed: 11/28/2022] Open
Abstract
PURPOSE A recent dose-finding study showed no significant differences in number of mature oocytes, embryos and top-quality embryos when triptorelin doses of 0.2, 0.3 or 0.4 mg were used to trigger final oocyte maturation in oocyte donors co-treated with a gonadotropin-releasing hormone (GnRH) antagonist. This analysis investigated whether triptorelin dosing for triggering final oocyte maturation in oocyte donors induced differences in follicular fluid (FF) hormone levels and granulosa cell gene expression. METHODS This single-centre, randomised, parallel, investigator-blinded trial was conducted in oocyte donors undergoing a single stimulation cycle at IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam, from August 2014 to March 2015. A total of 165 women aged 18-35 years with body mass index <28 kg/m2, anti-Müllerian hormone >1.25 ng/mL, and antral follicle count ≥6 were randomised to three different triptorelin doses for trigger. The main outcome was concentration of steroid hormones in FF collected from the first punctured follicle on each side. Moreover, luteinising hormone receptor (LHR), 3β-hydroxy-steroid-dehydrogenase (3ßHSD) and inhibin-Ba (INHB-A) gene expression in cumulus and mural granulosa cells were investigated in a subset of women from each group. RESULTS Progesterone and oestradiol levels in FF did not differ significantly by trigger doses; findings were similar for 3βHSD, LHR and INHB-A gene expression in both cumulus and mural granulosa cells. CONCLUSIONS In women co-treated with a GnRH antagonist, no significant differences in FF steroid levels and granulosa cell gene expression were seen when different triptorelin doses were used to trigger final oocyte maturation.
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Affiliation(s)
- Thi Ngoc Lan Vuong
- Department of Obstetrics and Gynaecology, University of Medicine and Pharmacy HCMC, 217 Hong Bang Street, District 5, Ho Chi Minh City, Vietnam. .,IVFMD, My Duc Hospital, 4 Nui Thanh Street, Tan Binh District, Ho Chi Minh City, Vietnam.
| | - M T Ho
- IVFMD, My Duc Hospital, 4 Nui Thanh Street, Tan Binh District, Ho Chi Minh City, Vietnam.,Research Center for Genetics and Reproductive Health (CGRH), School of Medicine, Vietnam National University HCMC, Room 608, VNU-HCM Administrative Building, Quarter 6, Linh Trung Ward, Thu Duc District, Ho Chi Minh City, Vietnam
| | - T Q Ha
- IVFMD, My Duc Hospital, 4 Nui Thanh Street, Tan Binh District, Ho Chi Minh City, Vietnam
| | - M Brehm Jensen
- Laboratory of Reproductive Biology, The Copenhagen University Hospital and Faculty of Health Science, Copenhagen University, Blegda msvej 9, 2100, Copenhagen, Denmark
| | - C Yding Andersen
- Laboratory of Reproductive Biology, The Copenhagen University Hospital and Faculty of Health Science, Copenhagen University, Blegda msvej 9, 2100, Copenhagen, Denmark
| | - P Humaidan
- The Fertility Clinic, Skive Regional Hospital, Resenvej 25, 7800, Skive, Denmark.,Faculty of Health, Aarhus University and Faculty of Health, University of Southern Denmark, Brendstrupgårdsvej 100, 8200, Aarhus, Denmark
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Şükür YE, Özmen B, Özdemir ED, Seval MM, Kalafat E, Sönmezer M, Berker B, Aytaç R, Atabekoğlu CS. Final oocyte maturation with two different GnRH agonists in antagonist co-treated cycles at risk of ovarian hyperstimulation syndrome. Reprod Biomed Online 2017; 34:5-10. [DOI: 10.1016/j.rbmo.2016.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 09/30/2016] [Accepted: 10/05/2016] [Indexed: 11/16/2022]
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Haahr T, Roque M, Esteves SC, Humaidan P. GnRH Agonist Trigger and LH Activity Luteal Phase Support versus hCG Trigger and Conventional Luteal Phase Support in Fresh Embryo Transfer IVF/ICSI Cycles-A Systematic PRISMA Review and Meta-analysis. Front Endocrinol (Lausanne) 2017; 8:116. [PMID: 28638367 PMCID: PMC5461358 DOI: 10.3389/fendo.2017.00116] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The use of GnRH agonist (GnRHa) for final oocyte maturation trigger in oocyte donation and elective frozen embryo transfer cycles is well established due to lower ovarian hyperstimulation syndrome (OHSS) rates as compared to hCG trigger. A recent Cochrane meta-analysis concluded that GnRHa trigger was associated with reduced live birth rates (LBRs) in fresh autologous IVF cycles compared to hCG trigger. However, the evidence is not unequivocal, and recent trials have found encouraging reproductive outcomes among couples undergoing GnRHa trigger and individualized luteal LH activity support. Thus, the aim was to compare GnRHa trigger followed by luteal LH activity support with hCG trigger in IVF patients undergoing fresh embryo transfer. MATERIAL AND METHODS We conducted a systematic review and meta-analysis of randomized trials published until December 14, 2016. The population was infertile patients submitted to IVF/ICSI cycles with GnRH antagonist cotreatment who underwent fresh embryo transfer. The intervention was GnRHa trigger followed by LH activity luteal phase support (LPS). The comparator was hCG trigger followed by a standard LPS. The critical outcome measures were LBR and OHSS rate. The secondary outcome measures were number of oocytes retrieved, clinical and ongoing pregnancy rates, and miscarriage rates. RESULTS A total of five studies met the selection criteria comprising a total of 859 patients. The LBR was not significantly different between the GnRHa and hCG trigger groups (OR 0.84, 95% CI 0.62, 1.14). OHSS was reported in a total of 4/413 cases in the GnRHa group compared to 7/413 in the hCG group (OR 0.48, 95% CI 0.15, 1.60). We observed a slight, but non-significant increase in miscarriage rate in the GnRHa triggered group compared to the hCG group (OR 1.85; 95% CI 0.97, 3.54). CONCLUSION GnRHa trigger with LH activity LPS resulted in comparable LBRs compared to hCG trigger. The most recent trials reported LBRs close to unity indicating that individualization of the LH activity LPS improved the luteal phase deficiency reported in the first GnRHa trigger studies. However, LPS optimization is needed to further limit OHSS in the subgroup of normoresponder patients (<14 follicles ≥ 11 mm). PROSPERO REGISTRATION NUMBER CRD42016051091.
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Affiliation(s)
- Thor Haahr
- The Fertility Clinic Skive Regional Hospital, Skive, Denmark
- Faculty of Health, Aarhus University, Aarhus C, Denmark
- *Correspondence: Thor Haahr,
| | - Matheus Roque
- ORIGEN – Center for Reproductive Medicine, Rio de Janeiro, Brazil
| | - Sandro C. Esteves
- Faculty of Health, Aarhus University, Aarhus C, Denmark
- ANDROFERT, Andrology and Human Reproduction Clinic, São Paulo, Brazil
- Department of Surgery, University of Campinas (UNICAMP), São Paulo, Brazil
| | - Peter Humaidan
- The Fertility Clinic Skive Regional Hospital, Skive, Denmark
- Faculty of Health, Aarhus University, Aarhus C, Denmark
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Lambertini M, Pescio MC, Viglietti G, Goldrat O, Del Mastro L, Anserini P, Demeestere I. Methods of controlled ovarian stimulation for embryo/oocyte cryopreservation in breast cancer patients. ACTA ACUST UNITED AC 2016. [DOI: 10.1080/23809000.2017.1270760] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Matteo Lambertini
- Breast Cancer Translational Research Laboratory, Institut Jules Bordet, Université Libre de Bruxelles (U.L.B.), Brussels, Belgium
- Breast Data Centre, Department of Medicine, Institut Jules Bordet, Université Libre de Bruxelles (U.L.B.), Brussels, Belgium
| | - Maria Carolina Pescio
- Department of Gynecology, U.O. di Ginecologia, Università di Genova, IRCCS AOU San Martino-IST, Genova, Italy
| | - Giulia Viglietti
- Breast Cancer Translational Research Laboratory, Institut Jules Bordet, Université Libre de Bruxelles (U.L.B.), Brussels, Belgium
| | - Oranite Goldrat
- Fertility Clinic, Research Laboratory on Human Reproduction Erasme and l’Université Libre de Bruxelles (U.L.B.), Brussels, Belgium
| | - Lucia Del Mastro
- Department of Medical Oncology, U.O. Sviluppo Terapie Innovative, IRCCS AOU San Martino-IST, Genova, Italy
| | - Paola Anserini
- Department of Gynecology, U.O. di Ginecologia, Università di Genova, IRCCS AOU San Martino-IST, Genova, Italy
| | - Isabelle Demeestere
- Fertility Clinic, Research Laboratory on Human Reproduction Erasme and l’Université Libre de Bruxelles (U.L.B.), Brussels, Belgium
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Kasum M, Kurdija K, Orešković S, Čehić E, Pavičić-Baldani D, Škrgatić L. Combined ovulation triggering with GnRH agonist and hCG in IVF patients. Gynecol Endocrinol 2016; 32:861-865. [PMID: 27275861 DOI: 10.1080/09513590.2016.1193141] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The aim of the review is to analyse the combination of a gonadotrophin releasing hormone (GnRH) agonist with a human chorionic gonadotrophin (hCG) trigger, for final oocyte maturation in in vitro fertilisation (IVF) cycles. The concept being a ''dual trigger'' combines a single dose of the GnRH agonist with a reduced or standard dosage of hCG at the time of triggering. The use of a GnRH agonist with a reduced dose of hCG in high responders demonstrated luteal phase support with improved pregnancy rates, similar to those after conventional hCG and a low risk of ovarian hyperstimulation syndrome (OHSS). The administration of a GnRH agonist and a standard hCG in normal responders, demonstrated significantly improved live-birth rates and a higher number of embryos of excellent quality, or cryopreserved embryos. The concept of the ''double trigger" represents a combination of a GnRH agonist and a standard hCG, when used 40 and 34 h prior to ovum pick-up, respectively. The use of the ''double trigger" has been successfully offered in the treatment of empty follicle syndrome and in patients with a history of immature oocytes retrieved or with low/poor oocytes yield. Further prospective studies are required to confirm the aforementioned observations prior to clinical implementation.
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Affiliation(s)
- Miro Kasum
- a Department of Obstetrics and Gynaecology , University Hospital Centre Zagreb, School of Medicine, University of Zagreb , Zagreb , Croatia and
| | - Kristijan Kurdija
- b Human Reproduction Unit, Maternity Hospital and Outpatient Clinic Podobnik , Zagreb , Croatia , and
| | - Slavko Orešković
- a Department of Obstetrics and Gynaecology , University Hospital Centre Zagreb, School of Medicine, University of Zagreb , Zagreb , Croatia and
| | - Ermin Čehić
- c Human Reproduction Unit, Cantonal Hospital Zenica , Zenica , Bosnia and Herzegovina
| | - Dinka Pavičić-Baldani
- a Department of Obstetrics and Gynaecology , University Hospital Centre Zagreb, School of Medicine, University of Zagreb , Zagreb , Croatia and
| | - Lana Škrgatić
- a Department of Obstetrics and Gynaecology , University Hospital Centre Zagreb, School of Medicine, University of Zagreb , Zagreb , Croatia and
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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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[Is gonadotropin releasing hormone (GnRH) agonist trigger beneficial or deleterious?]. ACTA ACUST UNITED AC 2016; 44:403-9. [PMID: 27451069 DOI: 10.1016/j.gyobfe.2016.05.013] [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: 03/07/2016] [Accepted: 05/26/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The undeniable asset of the antagonist protocols in in vitro fertilization is the decrease of the risks of ovarian hyperstimulation syndrome, by the use of a release by GnRH agonist. Nevertheless, questioning persist concerning the rates of clinical pregnancies, the oocyte quantity and the empty follicle syndrome. We thus studied these parameters in our center. METHODS A retrospective study was realized from January 1st, 2013 till July 31st, 2015. The main objective was the evaluation of the rate of clinical pregnancies in antagonist protocol. A first group of 775 cycles have benefited from a release of the ovulation by HCG, while a second group of 204 cycles, by GnRH agonist. The secondary objectives were the oocyte quantity, the rate of ovarian hyperstimulation syndrome, and the rate of empty follicle syndrome. RESULTS No statistically significant difference was found between both groups concerning the rates of clinical pregnancies, oocytes quantity, and the rate of empty follicle syndrome, whatever is the type of used release, in fresh embryo transfer. A syndrome of premature ovarian hyperstimulation syndrome was found at 7.9 % of the patients in the group 2 versus 2.3 % in the group 1, with a statistically significant difference (P<0.05). At these patients, a strategy of frozen embryo transfer ("freeze all") was proposed. The accumulated rates by pregnancy in both groups were not statistically different. CONCLUSION The release by GnRH agonist does not show inferiority in terms of clinical pregnancy, in comparison to HCG.
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Fischer D, Reisenbüchler C, Rösner S, Haussmann J, Wimberger P, Goeckenjan M. Avoiding OHSS: Controlled Ovarian Low-Dose Stimulation in Women with PCOS. Geburtshilfe Frauenheilkd 2016; 76:718-726. [PMID: 27365543 DOI: 10.1055/s-0042-100206] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The polycystic ovary syndrome is a common endocrine disorder which influences outcome and potential risks involved with controlled ovarian stimulation for artificial reproductive techniques (ART). Concrete practical recommendations for the dosage of gonadotropins, the preferred protocol and preventive methods to avoid ovarian hyperstimulation syndrome (OHSS) are lacking. We present retrospective data of 235 individually calculated gonadotropin low-dose stimulations for ART in a single center from 2012 to 2014. Clinical data and outcome parameter of patients diagnosed with PCOS according to Rotterdam criteria (n = 39) were compared with patients without PCOS (n = 196). The starting dose of gonadotropins was individually calculated depending on patients' age, BMI, ovarian reserve, ovarian response in previous cycles, and diagnostic criteria of PCOS. Mean age and duration of infertility did not differ between the groups, whereas mean BMI (p = 0.007) and AMH (p < 0.001) were higher in the PCOS-group. A lower mean FSH-starting and maximum dose was administered to women with PCOS (p < 0.001). The biochemical pregnancy rate of 42.4 % and the clinical pregnancy rate of 32.2 % for PCOS-patients did not differ from those of the control group (42.2 % and 34.4 % respectively). Neither mild, nor moderate or severe manifestation of OHSS occurred significantly more often in patients with PCOS. Our study supports the use of a calculated low-dose FSH-stimulation strategy in ART for patients with PCOS. Further randomized clinical trials should confirm this strategy and lead to define individual risk factors for OHSS, which can be used for recommendation of safer ART-techniques like in vitro maturation.
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Affiliation(s)
- D Fischer
- University Hospital of Gynecology and Obstetrics, Technical University, Dresden
| | - C Reisenbüchler
- University Hospital of Gynecology and Obstetrics, Technical University, Dresden
| | - S Rösner
- University Hospital of Heidelberg, Department of Gynecological Endocrinology and Reproductive Medicine, Heidelberg
| | - J Haussmann
- University Hospital of Gynecology and Obstetrics, Technical University, Dresden
| | - P Wimberger
- University Hospital of Gynecology and Obstetrics, Technical University, Dresden
| | - M Goeckenjan
- University Hospital of Gynecology and Obstetrics, Technical University, Dresden
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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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Engmann L, Benadiva C, Humaidan P. GnRH agonist trigger for the induction of oocyte maturation in GnRH antagonist IVF cycles: a SWOT analysis. Reprod Biomed Online 2016; 32:274-85. [PMID: 26803205 DOI: 10.1016/j.rbmo.2015.12.007] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Revised: 12/19/2015] [Accepted: 12/22/2015] [Indexed: 01/26/2023]
Abstract
Gonadotrophin releasing hormone agonist (GnRHa) trigger is effective in the induction of oocyte maturation and prevention of ovarian hyperstimulation syndrome during IVF treatment. This trigger concept, however, results in early corpora lutea demise and consequently luteal phase dysfunction and impaired endometrial receptivity. The aim of this strenghths, weaknesses, opportunities and threats analysis was to summarize the progress made over the past 15 years to optimize ongoing pregnancy rates after GnRHa trigger. The advantages and potential drawbacks of this type of triggering are reviewed. The current approach to the management of GnRHa trigger in autologous cycles is based on the peak serum oestradiol level or follicle number and aims at a fresh embryo transfer or a segmentation approach with elective cryopreservation policy. We recommend intensive luteal support with transdermal oestradiol and intramuscular progesterone alone if peak serum oestradiol is 4000 or more pg/ml after GnRHa trigger or dual trigger with GnRHa and HCG 1000 IU if peak serum oestradiol is less than 4000 pg/mL. On the contrary, we recommend HCG 1500 IU 35 h after GnRHa trigger if there are less than 25 follicles, or freeze all oocytes or embryos if there are over 25 follicles.
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Affiliation(s)
- Lawrence Engmann
- Department of Obstetrics and Gynecology, Center for Advanced Reproductive Services, University of Connecticut School of Medicine, 2 Batterson Park Road, Farmington, CT, USA.
| | - Claudio Benadiva
- Department of Obstetrics and Gynecology, Center for Advanced Reproductive Services, University of Connecticut School of Medicine, 2 Batterson Park Road, Farmington, CT, USA
| | - Peter Humaidan
- The Fertility Clinic, Skive Regional Hospital and Faculty of Health, Aarhus University, Resenvej 25, 7800 Skive, Denmark
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Yarali H, Bozdag G, Polat M, Yarali I, Humaidan P. Spontaneous clinical pregnancy following GNRH agonist trigger for final oocyte maturation and freeze-all approach: a case report. Reprod Biomed Online 2015; 32:233-6. [PMID: 26673103 DOI: 10.1016/j.rbmo.2015.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 09/16/2015] [Accepted: 11/05/2015] [Indexed: 11/27/2022]
Abstract
We herein describe a 34-year old infertile woman with polycystic ovary syndrome who was underwent follicle stimulation with a gonadotrophin-releasing hormone (GnRH) agonist, and a freeze-all approach, but still conceived spontaneously without any luteal phase support and without development of ovarian hyperstimulation syndrome. The bilateral antral follicle count of the patient was 22. A fixed GnRH antagonist protocol was used. As the number of follicles wider than 11 mm in diameter on the day of stimulation was 28, the final oocyte maturation was triggered by a GnRH agonist and a freeze-all approach was taken. Although no luteal phase support was used after trigger, the patient conceived spontaneously. In conclusion, the endogenous LH level during the luteal phase may be sufficiently high in selected cases to rescue some of the corpora lutea even when a GnRH agonist has been administered for final oocyte maturation. When a freeze-all approach is taken to avoid ovarian hyperstimulation syndrome, couples should be strictly advised to refrain from sexual intercourse after oocyte retrieval.
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Affiliation(s)
- Hakan Yarali
- Anatolia Women's Health and IVF Center, Ankara, Turkey; Department of Obstetrics and Gynecology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.
| | - Gürkan Bozdag
- Department of Obstetrics and Gynecology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Mehtap Polat
- Anatolia Women's Health and IVF Center, Ankara, Turkey
| | - Irem Yarali
- Anatolia Women's Health and IVF Center, Ankara, Turkey
| | - Peter Humaidan
- Fertility Clinic, Skive Regional Hospital and Faculty of Health, Aarhus University, Aarhus, Denmark
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Palomba S, Santagni S, La Sala GB. Progesterone administration for luteal phase deficiency in human reproduction: an old or new issue? J Ovarian Res 2015; 8:77. [PMID: 26585269 PMCID: PMC4653859 DOI: 10.1186/s13048-015-0205-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 11/11/2015] [Indexed: 12/25/2022] Open
Abstract
Luteal phase deficiency (LPD) is described as a condition of insufficient progesterone exposure to maintain a regular secretory endometrium and allow for normal embryo implantation and growth. Recently, scientific focus is turning to understand the physiology of implantation, in particular the several molecular markers of endometrial competence, through the recent transcriptomic approaches and microarray technology. In spite of the wide availability of clinical and instrumental methods for assessing endometrial competence, reproducible and reliable diagnostic tests for LPD are currently lacking, so no type-IA evidence has been proposed by the main scientific societies for assessing endometrial competence in infertile couples. Nevertheless, LPD is a very common condition that may occur during a series of clinical conditions, and during controlled ovarian stimulation (COS) and hyperstimulation (COH) programs. In many cases, the correct approach to treat LPD is the identification and correction of any underlying condition while, in case of no underlying dysfunction, the treatment becomes empiric. To date, no direct data is available regarding the efficacy of luteal phase support for improving fertility in spontaneous cycles or in non-gonadotropin induced ovulatory cycles. On the contrary, in gonadotropin in vitro fertilization (IVF) and non-IVF cycles, LPD is always present and progesterone exerts a significant positive effect on reproductive outcomes. The scientific debate still remains open regarding progesterone administration protocols, specially on routes of administration, dose and timing and the potential association with other drugs, and further research is still needed.
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Affiliation(s)
- Stefano Palomba
- Centre of Reproductive Medicine and Surgery, Arcispedale Santa Maria Nuova - IRCCS, Viale Risorgimento 80, 42123, Reggio Emilia, Italy.
| | - Susanna Santagni
- Centre of Reproductive Medicine and Surgery, Arcispedale Santa Maria Nuova - IRCCS, Viale Risorgimento 80, 42123, Reggio Emilia, Italy.
| | - Giovanni Battista La Sala
- Centre of Reproductive Medicine and Surgery, Arcispedale Santa Maria Nuova - IRCCS, University of Modena and Reggio Emilia, Via Università 4, 41100 Viale Risorgimento 80, 42123, Modena, Italy.
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Gat I, Shlush E, Quach K, Librach CL. The continuum of high ovarian response: a rational approach to the management of high responder patient subgroups. Syst Biol Reprod Med 2015; 61:336-44. [PMID: 26516651 DOI: 10.3109/19396368.2015.1089607] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Ovarian follicular responsiveness to controlled ovarian hyperstimulation (COH) with gonadotropins is extremely variable between individual patients, and even from cycle to cycle for the same patient. High responder patients are characterized by an exaggerated response to gonadotropin administration, accompanied by a higher risk for ovarian hyperstimulation syndrome (OHSS). In spite of its importance, the literature regarding high responders is characterized by heterogeneous classification methodologies. A clear separation should be drawn between risk factors for a high ovarian response and the actual response exhibited by a patient to stimulation. Similarly, it is important to distinguish between high ovarian response and development of clinically significant OHSS. In this article we: (1) review recent publications pertaining to the identification and clinical management of high responders, (2) propose an integrated clinical model to differentiate sub-groups within this population based on this review, and (3) suggest specific protocols for each sub-group. The model is based on a chronological patient assessment in an effort to target treatment based on the specific clinical circumstances. It is our hope that the algorithm we have developed will assist clinicians to supply targeted and precise treatments in order to achieve a favorable reproductive outcome with minimum complications for each patient.
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Affiliation(s)
- Itai Gat
- a CReATe Fertility Centre , Toronto , Ontario , Canada .,b Pinchas Borenstein Talpiot Medical Leadership Program, Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel; Affiliated to Sackler Medical School, University of Tel Aviv , Israel , and
| | | | - Kevin Quach
- a CReATe Fertility Centre , Toronto , Ontario , Canada
| | - Clifford L Librach
- a CReATe Fertility Centre , Toronto , Ontario , Canada .,c Department of Obstetrics and Gynecology , University of Toronto , Ontario , Canada
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