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Youngster M, Moran E, Luz A, Reuvenny S, Hourvitz R, Bashi TBM, Baum M, Maman E, Hourvitz A. Intrauterine insemination timing models-LH can only take you so far. J Assist Reprod Genet 2024:10.1007/s10815-024-03135-4. [PMID: 38755491 DOI: 10.1007/s10815-024-03135-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 05/03/2024] [Indexed: 05/18/2024] Open
Abstract
RESEARCH QUESTION Can an optimal LH threshold algorithm accurately predict timing of ovulation for natural cycle-intrauterine insemination (NC-IUI)? DESIGN A retrospective cohort study (2018-2022) including 2467 natural cycles. Ovulation timing for these cycles was determined using a previously developed AI model. Two LH thresholds, low and high, were determined in the LH algorithm. Being below the low threshold meant that ovulation is likely to occur in ≥ 4 days, suggesting another daily blood test. Between the two thresholds meant that ovulation was likely in 2-3 days, suggesting IUI the next day. Above the high threshold meant that ovulation will likely occur tomorrow, suggesting performing IUI on the same day. RESULTS The optimal LH model with a high threshold of 40 mIU/ml and a low threshold of 11 mIU/ml succeeded in correctly predicting timing for IUI (day - 1, - 2 relative to ovulation) in 75.4% (95%CI 75.3-75.4). In 23.1% (95%CI 23.0-23.2), the algorithm predicted "error," suggesting performing insemination when in fact it would have been performed on a non-optimal day (0 or - 3). A previously described 3-hormone-based (LH, estradiol, progesterone) AI model performed significantly better in all parameters (93.6% success rate, 4.3 "error" rate). CONCLUSIONS An LH threshold model, representing common practice, evaluating all possible high and low LH threshold combinations, was successful in accurately scheduling timing for IUI in only 75% of cases. Integrating all three hormones as performed in the AI model may have an advantage in accurately predicting the optimal time for IUI, over the use of LH only.
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Affiliation(s)
- Michal Youngster
- IVF Unit, Department of Obstetrics and Gynecology, Shamir Medical Center, Assaf Harofeh, 70300, Zerifin, Israel.
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel.
| | | | | | | | | | - Tali Ben-Mayor Bashi
- Department of Obstetrics and Gynecology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Micha Baum
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
- FertilAi, Ramat-Gan, Israel
- IVF Unit, Herzliya Medical Centre, Herzliya, Israel
- IVF Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Ramat-Gan, Israel
| | - Ettie Maman
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
- FertilAi, Ramat-Gan, Israel
- IVF Unit, Herzliya Medical Centre, Herzliya, Israel
- IVF Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Ramat-Gan, Israel
| | - Ariel Hourvitz
- IVF Unit, Department of Obstetrics and Gynecology, Shamir Medical Center, Assaf Harofeh, 70300, Zerifin, Israel
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
- FertilAi, Ramat-Gan, Israel
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Maman E, Adashi EY, Baum M, Hourvitz A. Prediction of ovulation: new insight into an old challenge. Sci Rep 2023; 13:20003. [PMID: 37968377 PMCID: PMC10651856 DOI: 10.1038/s41598-023-47241-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 11/10/2023] [Indexed: 11/17/2023] Open
Abstract
Ultrasound monitoring and hormonal blood testing are considered by many as an accurate method to predict ovulation time. However, uniform and validated algorithms for predicting ovulation have yet to be defined. Daily hormonal tests and transvaginal ultrasounds were recorded to develop an algorithm for ovulation prediction. The rupture of the leading ovarian follicle was a marker for ovulation day. The model was validated retrospectively on natural cycles frozen embryo transfer cycles with documented ovulation. Circulating levels of LH or its relative variation failed, by themselves, to reliably predict ovulation. Any decrease in estrogen was 100% associated with ovulation emergence the same day or the next day. Progesterone levels > 2 nmol/L had low specificity to predict ovulation the next day (62.7%), yet its sensitivity was high (91.5%). A model for ovulation prediction, combining the three hormone levels and ultrasound was created with an accuracy of 95% to 100% depending on the combination of the hormone levels. Model validation showed correct ovulation prediction in 97% of these cycles. We present an accurate ovulation prediction algorithm. The algorithm is simple and user-friendly so both reproductive endocrinologists and general practitioners can use it to benefit their patients.
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Affiliation(s)
- Ettie Maman
- Sheba Medical Center In Vitro Fertilization Unit, Department of Obstetrics and Gynecology. Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel.
- Herzliya Medical Center, In Vitro Fertilization Unit, Herzliya, Israel.
| | - Eli Y Adashi
- Departments of Medical Science and Obstetrics and Gynecology, the Warren Alpert Medical School, Brown University, Providence, RI, 02906, USA
| | - Micha Baum
- Sheba Medical Center In Vitro Fertilization Unit, Department of Obstetrics and Gynecology. Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
- Herzliya Medical Center, In Vitro Fertilization Unit, Herzliya, Israel
| | - Ariel Hourvitz
- Shamir Medical Center In Vitro Fertilization Unit, Department of Obstetrics and Gynecology. Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
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Youngster M, Luz A, Baum M, Hourvitz R, Reuvenny S, Maman E, Hourvitz A. Artificial intelligence in the service of intrauterine insemination and timed intercourse in spontaneous cycles. Fertil Steril 2023; 120:1004-1012. [PMID: 37490977 DOI: 10.1016/j.fertnstert.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 07/06/2023] [Accepted: 07/18/2023] [Indexed: 07/27/2023]
Abstract
OBJECTIVE To develop a machine learning model designed to predict the time of ovulation and optimal fertilization window for performing intrauterine insemination or timed intercourse (TI) in natural cycles. DESIGN A retrospective cohort study. SETTING A large in vitro fertilization unit. PATIENT(S) Patients who underwent 2,467 natural cycle-frozen embryo transfer cycles between 2018 and 2022. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Prediction accuracy of the optimal day for performing insemination or TI. RESULT(S) The data set was split into a training set including 1,864 cycles and 2 test sets. In the test sets, ovulation was determined according to either expert opinion, with 2 independent fertility experts determining ovulation day ("expert") (496 cycles), or according to the disappearance of the leading follicle between 2 consecutive days' ultrasound examinations ("certain ovulation") (107 cycles). Two algorithms were trained: an NGBoost machine learning model estimating the probability of ovulation occurring on each cycle day and a treatment management algorithm using the learning model to determine an optimal insemination day or whether another blood test should be performed. The estradiol progesterone and luteinizing hormone levels on the last test performed were the most influential features used by the model. The mean numbers of tests were 2.78 and 2.85 for the "certain ovulation" and "expert" test sets, respectively. In the "expert" set, the algorithm correctly predicted ovulation and suggested day 1 or 2 for performing insemination in 92.9% of the cases. In 2.9%, the algorithm predicted a "miss," meaning that the last test day was already ovulation day or beyond, suggesting avoiding performing insemination. In 4.2%, the algorithm predicted an "error," suggesting performing insemination when in fact it would have been performed on a nonoptimal day (0 or -3). The "certain ovulation" set had similar results. CONCLUSION(S) To our knowledge, this is the first study to implement a machine learning model, on the basis of the blood tests only, for scheduling insemination or TI with high accuracy, attributed to the capability of the algorithm to integrate multiple factors and not rely solely on the luteinizing hormone surge. Introducing the capabilities of the model may improve the accuracy and efficiency of ovulation prediction and increase the chance of conception. CLINICAL TRIAL REGISTRATION NUMBER HMC-0008-21.
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Affiliation(s)
- Michal Youngster
- IVF Unit, Department of Obstetrics and Gynecology, Shamir Medical Center, Zerifin, Israel; Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel.
| | | | - Micha Baum
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel; FertilAi, Ramat Gan, Israel; IVF Unit, Herzliya Medical Centre, Herzliya, Israel; IVF Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Ramat-Gan, Israel
| | | | | | - Ettie Maman
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel; FertilAi, Ramat Gan, Israel; IVF Unit, Herzliya Medical Centre, Herzliya, Israel; IVF Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Ramat-Gan, Israel
| | - Ariel Hourvitz
- IVF Unit, Department of Obstetrics and Gynecology, Shamir Medical Center, Zerifin, Israel; Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel; FertilAi, Ramat Gan, Israel
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Zaat T, de Bruin JP, Goddijn M, van Baal M, Benneheij S, Brandes M, Broekmans F, Cantineau A, Cohlen B, van Disseldorp J, Gielen S, Groenewoud E, van Heusden A, Kaaijk E, Koks C, de Koning C, Klijn N, van der Linden P, Manger P, Moolenaar L, van Oppenraaij R, Pieterse Q, Smeenk J, Visser J, van Wely M, Mol F. Home-based monitoring of ovulation to time frozen embryo transfers in the Netherlands (Antarctica-2): an open-label, nationwide, randomised, non-inferiority trial. Lancet 2023; 402:1347-1355. [PMID: 37678290 DOI: 10.1016/s0140-6736(23)01312-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/02/2023] [Accepted: 06/22/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND The growing field of assisted reproductive techniques, including frozen-thawed embryo transfer (FET), should lead the way to the best sustainable health care without compromising pregnancy chances. Correct timing of FET is crucial to allow implantation of the thawed embryo. Nowadays, timing based on hospital-controlled monitoring of ovulation in the natural cycle of a woman is the preferred strategy because of the assumption of favourable fertility prospects. However, home-based monitoring is a simple method to prevent patient travel and any associated environmental concerns. We compared ongoing pregnancy rates after home-based monitoring versus hospital-controlled monitoring with ovulation triggering. METHODS This open-label, multicentre, randomised, non-inferiority trial was undertaken in 23 hospitals and clinics in the Netherlands. Women aged between 18 and 44 years with a regular ovulatory menstrual cycle were randomly assigned in a 1:1 ratio via a web-based randomisation program to home-based monitoring or hospital-controlled monitoring. Those who analysed the data were masked to the groups; those collecting the data were not. All endpoints were analysed by intention to treat and per protocol. Non-inferiority was established when the lower limit of the 90% CI exceeded -4%. This study was registered at the Dutch Trial Register (Trial NL6414). FINDINGS 1464 women were randomly assigned between April 10, 2018, and April 13, 2022, with 732 allocated to home-based monitoring and 732 to hospital-controlled monitoring. Ongoing pregnancy occurred in 152 (20·8%) of 732 in the home-based monitoring group and in 153 (20·9%) of 732 in the hospital-controlled monitoring group (risk ratio [RR] 0·99 [90% CI 0·81 to 1·22]; risk difference [RD] -0·14 [90% CI -3·63 to 3·36]). The per-protocol analysis confirmed non-inferiority (152 [21·0%] of 725 vs 153 [21·0%] of 727; RR 1·00 (90% CI 0·81 to 1·23); RD -0·08 [90% CI -3·60 to 3·44]). INTERPRETATION Home-based monitoring of ovulation is non-inferior to hospital-controlled monitoring of ovulation to time FET. FUNDING The Dutch Organisation for Health Research and Development.
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Affiliation(s)
- Tjitske Zaat
- Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
| | - Jan-Peter de Bruin
- Department of Obstetrics and Gynaecology, Jeroen Bosch Ziekenhuis, 's-Hertogenbosch, Netherlands
| | - Mariëtte Goddijn
- Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
| | - Marchien van Baal
- Department of Obstetrics and Gynaecology, Flevoziekenhuis, Almere, Netherlands
| | - Sofie Benneheij
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Monique Brandes
- Centre for Reproductive Medicine Nij Geertgen, Elsendorp, Netherlands
| | - Frank Broekmans
- Department of Reproductive Medicine, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Astrid Cantineau
- Centre for Reproductive Medicine, University Medical Centre Groningen, Groningen, Netherlands
| | - Ben Cohlen
- Isala Fertility Centre, Isala Clinics, Zwolle, Netherlands
| | - Jeroen van Disseldorp
- Department of Obstetrics and Gynaecology, Sint Antonius Hospital, Nieuwegein, Netherlands
| | - Susanne Gielen
- Department of Obstetrics and Gynaecology, Franciscus Hospital, Rotterdam, Netherlands
| | - Eva Groenewoud
- Department of Obstetrics and Gynaecology, Noordwest Ziekenhuisgroep, Den Helder, Netherlands
| | | | - Eugenie Kaaijk
- Department of Obstetrics and Gynaecology, OLVG, Amsterdam, Netherlands
| | - Carolien Koks
- Department of Obstetrics and Gynaecology, Maxima Medical Centre, Veldhoven, Netherlands
| | - Corry de Koning
- Department of Obstetrics and Gynaecology, Tergooi Medical Centre, Blaricum, Netherlands
| | - Nicole Klijn
- Reproductive Centre, Leiden University Medical Centre, Leiden, Netherlands
| | - Paul van der Linden
- Department of Obstetrics and Gynaecology, Deventer Hospital, Deventer, Netherlands
| | - Petra Manger
- Department of Obstetrics and Gynaecology, Diakonessenhuis, Utrecht, Netherlands
| | - Lobke Moolenaar
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, Centre for Reproductive Medicine, Amsterdam, Netherlands
| | | | - Quirine Pieterse
- Department of Obstetrics and Gynaecology, Haga Ziekenhuis, Den Haag, Netherlands
| | - Jesper Smeenk
- Department of Obstetrics and Gynaecology, Elisabeth-TweeSteden Ziekenhuis, Tilburg, Netherlands
| | - Jantien Visser
- Department of Obstetrics and Gynaecology, Amphia Ziekenhuis, Breda, Netherlands
| | - Madelon van Wely
- Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
| | - Femke Mol
- Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands.
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Coughlan C, Ata B, Gallego RD, Lawrenz B, Melado L, Samir S, Fatemi H. Interindividual variation of progesterone elevation post LH rise: implications for natural cycle frozen embryo transfers in the individualized medicine era. Reprod Biol Endocrinol 2023; 21:47. [PMID: 37202769 DOI: 10.1186/s12958-023-01096-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 05/02/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND The key to optimal timing of frozen embryo transfer (FET ) is to synchronize the embryo with the receptive phase of the endometrium. Secretory transformation of the endometrium is induced by progesterone. In contrast, detection of the luteinizing hormone (LH) surge is the most common surrogate used to determine the start of secretory transformation and to schedule FET in a natural cycle. The accuracy of LH monitoring to schedule FET in a natural cycle relies heavily on the assumption that the period between the LH surge and ovulation is acceptably constant. This study will determine the period between LH rise and progesterone rise in ovulatory natural menstrual cycles. METHODS Retrospective observational study including 102 women who underwent ultrasound and endocrine monitoring for a frozen embryo transfer in a natural cycle. All women had serum LH, estradiol and progesterone levels measured on three consecutive days until (including) the day of ovulation defined with serum progesterone level exceeding 1ng/ml. RESULTS Twenty-one (20.6%) women had the LH rise 2 days prior to progesterone rise, 71 (69.6%) had on the day immediately preceding progesterone rise and 10 (9.8%) on the same day of progesterone rise. Women who had LH rise 2 days prior to progesterone rise had significantly higher body mass index and significantly lower serum AMH levels than women who had LH rise on the same day with progesterone rise. CONCLUSION This study provides an unbiased account of the temporal relationship between LH and progesterone increase in a natural menstrual cycle. Variation in the period between LH rise and progesterone rise in ovulatory cycles likely has implications for the choice of marker for the start of secretory transformation in frozen embryo transfer cycles. The study participants are representative of the relevant population of women undergoing frozen embryo transfer in a natural cycle.
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Affiliation(s)
- Carol Coughlan
- ART Fertility Clinic, Dubai, UAE.
- ART Fertility Clinic, Abu Dhabi, UAE.
| | - Baris Ata
- ART Fertility Clinic, Dubai, UAE
- ART Fertility Clinic, Abu Dhabi, UAE
- Faculty of Medicine, Department of Obstetrics & Gynecology, Koc University, Istanbul, Turkey
| | | | - Barbara Lawrenz
- ART Fertility Clinic, Abu Dhabi, UAE
- Women's University Hospital, Tuebingen, Germany
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Bilgory A, Atzmon Y, Aslih N, Shibli Abu Raya Y, Sharqawi M, Shavit M, Estrada D, Shalom-Paz E. Ovulatory-cycle frozen embryo transfer: spontaneous or triggered ovulation and the impact of LH elevation at hCG triggering. Sci Rep 2023; 13:7195. [PMID: 37137911 PMCID: PMC10156802 DOI: 10.1038/s41598-023-34017-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 04/22/2023] [Indexed: 05/05/2023] Open
Abstract
The effect of the luteinizing hormone (LH) elevation before the human chorionic gonadotropin (hCG) trigger in ovulatory frozen-thawed embryo transfer (Ovu-FET) cycles has not been determined. We aimed to investigate whether triggering ovulation in Ovu-FET cycles affects the live birth rate (LBR), and the contribution of elevated LH at the time of hCG trigger. This retrospective study included Ovu-FET cycles performed in our center from August 2016 to April 2021. Modified Ovu-FET (hCG trigger) and true Ovu-FET (without hCG trigger) were compared. The modified group was divided according to whether hCG was administered, before or after LH increased to > 15 IU/L and was twice the baseline value. The modified (n = 100) and true (n = 246) Ovu-FET groups and both subgroups of the modified Ovu-FET, those who were triggered before (n = 67) or after (n = 33) LH elevation, had comparable characteristics at baseline. Comparison of true vs. modified Ovu-FET outcomes revealed similar LBR (35.4% vs. 32.0%; P = 0.62), respectively. LBR were similar between the modified Ovu-FET subgroups regardless of the hCG trigger timing (31.3% before vs. 33.3% after LH elevation; P = 0.84). In conclusion, LBR of Ovu-FET were not affected by hCG trigger or whether LH was elevated at the time of hCG trigger. These results add reassurance regarding hCG triggering even after LH elevation.
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Affiliation(s)
- Asaf Bilgory
- IVF Unit, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel.
- Ruth and Bruce Rappaport School of Medicine, The Technion Institute of Technology, Haifa, Israel.
| | - Yuval Atzmon
- IVF Unit, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel
- Ruth and Bruce Rappaport School of Medicine, The Technion Institute of Technology, Haifa, Israel
| | - Nardin Aslih
- IVF Unit, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel
- Ruth and Bruce Rappaport School of Medicine, The Technion Institute of Technology, Haifa, Israel
| | - Yasmin Shibli Abu Raya
- IVF Unit, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel
- Ruth and Bruce Rappaport School of Medicine, The Technion Institute of Technology, Haifa, Israel
| | - Moamina Sharqawi
- IVF Unit, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel
- Ruth and Bruce Rappaport School of Medicine, The Technion Institute of Technology, Haifa, Israel
| | - Maya Shavit
- IVF Unit, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel
- Ruth and Bruce Rappaport School of Medicine, The Technion Institute of Technology, Haifa, Israel
| | - Daniela Estrada
- IVF Unit, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel
- Ruth and Bruce Rappaport School of Medicine, The Technion Institute of Technology, Haifa, Israel
| | - Einat Shalom-Paz
- IVF Unit, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel
- Ruth and Bruce Rappaport School of Medicine, The Technion Institute of Technology, Haifa, Israel
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Jiang WJ, Sun ZG, Song JY. Premature timing of progesterone luteal phase support initiation did not negatively impact live birth rates in modified natural frozen thawed embryo transfer cycles. Heliyon 2023; 9:e13218. [PMID: 36793963 PMCID: PMC9922970 DOI: 10.1016/j.heliyon.2023.e13218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/20/2023] [Accepted: 01/20/2023] [Indexed: 01/26/2023] Open
Abstract
Study question In a modified natural cycle frozen-thawed embryo transfer (mNC-FET), does the premature timing of progesterone luteal phase support (LPS) initiation 24 h following human chorionic gonadotropin (hCG) trigger impact live birth? Summary answer Premature LPS initiation did not negatively affect the live birth rate (LBR) in mNC-FET cycles compared with conventional LPS initiation 48 h after hCG triggering. What is known already During natural cycle FET, human chorionic gonadotropin is routinely used to mimic endogenous luteinizing hormone (LH) surge to induce ovulation, which allows more flexibility in embryo transfer scheduling, thus relieving the burden of multiple visits by patients and laboratory workloads, which is also known as mNC-FET. Moreover, recent data demonstrates that ovulatory women undergoing natural cycle FETs have a lower risk of maternal and fetal complications due to the essential role of the corpus luteum in implantation, placentation and pregnancy maintenance. While several studies have confirmed the positive effects of LPS in mNC-FETs, the timing of progesterone LPS initiation is still unclear, as compared with fresh cycles where robust research has been conducted. To the best of our knowledge, no clinical studies comparing different beginning days in mNC-FET cycles have been published. Study design size duration This retrospective cohort study involved 756 mNC-FET cycles performed at a university-affiliated reproductive center between January 2019 and August 2021. The primary outcome measured was the LBR. Participants/materials setting methods Ovulatory women ≤42 years of age who were referred for their autologous mNC-FET cycles were included in the study. According to the timing of progesterone LPS initiation following the hCG trigger, patients were assigned into two categories: premature LPS group (progesterone initiation 24 h after hCG trigger, n = 182) versus conventional LPS group (progesterone initiation 48 h after hCG trigger, n = 574). Multivariate logistic regression analysis was used to control for confounding variables. Main results and the role of chance There were no differences in background characteristics between the two study groups, except for the proportion of assisted hatching (53.8% in premature LPS group versus 42.3% in conventional LPS group, p = 0.007). In the premature LPS group, 56 of 182 patients (30.8%) had a live birth, compared to 179 of 574 patients (31.2%) in the conventional LPS group, with no significant difference observed between groups (adjusted odds ratio [aOR] 0.98, 95% confidence interval [CI] 0.67-1.43, p = 0.913). In addition, there was no significant difference between the two groups in other secondary outcomes. A sensitivity analysis for LBR according to the serum LH and progesterone levels on hCG trigger day also confirmed the aforementioned findings. Limitations reasons for caution In this study, retrospective analysis was conducted in a single center and was therefore prone to bias. Additionally, we did not anticipate monitoring the patient's follicle rupture and ovulation after hCG triggering. Future prospective clinical trials remain necessary to confirm our results. Wider implications of the findings While exogenous progesterone LPS was added 24 h after hCG triggering, embryo-endometrium synchrony would not be adversely affected so long as sufficient time was allowed for endometrial exposure to exogenous progesterone. Our data support promising clinical outcomes following this event. As a result of our findings, clinicians and patients will be able to make better informed decisions. Study funding/competing interests No specific funding was available for this study. The authors have no personal conflicting interests to declare. Trial registration number N/A.
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Affiliation(s)
- Wen-Jing Jiang
- The First Clinical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Zhen-Gao Sun
- Reproductive Center of Integrated Medicine, The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China,Corresponding author.
| | - Jing-Yan Song
- The First Clinical College, Shandong University of Traditional Chinese Medicine, Jinan, China,Reproductive Center of Integrated Medicine, The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China,Corresponding author. The First Clinical College, Shandong University of Traditional Chinese Medicine, Jinan, China.
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Aydin T, Namli Kalem M, Bakirarar B, Aygun EG, Kalem Z. Comparing the success rate of natural cycle and modified natural cycle protocols for frozen-thawed embryo transfer. Gynecol Endocrinol 2022; 38:1073-1078. [PMID: 36220075 DOI: 10.1080/09513590.2022.2128747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
Objective: The aim of the present study is to compare the effects of Natural Cycle and modified Natural Cycle protocols for frozen-thawed embryo transfer on clinical pregnancy rate and live birth rate. Methods: This prospective randomized controlled trial comprised 145 patients scheduled for frozen-thawed embryo transfer and was conducted at a university hospital between 2019 and 2021. The Natural Cycle protocol was administered to 73 patients and the modified Natural Cycle protocol to 72 patients and the clinical outcome was compared between the groups. The main outcome measure was live birth rate. Results: Baseline characteristics and cycle parameters were similar in both groups. There was no difference in clinical pregnancy rate (58.9% and 54.2%, respectively; p = .565) and live birth rate between the Natural Cycle and modified Natural Cycle groups (49.3% and 48.6% respectively; p = .932). Conclusion: This study established that clinical pregnancy and live birth rates were not affected by natural cycle ovulation being spontaneous or hCG-triggered among patients undergoing frozen-thawed embryo transfer. Thus, the protocol for natural cycle frozen-thawed embryo transfers should be chosen according to the priorities of the patient and the physician.
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Affiliation(s)
- Turgut Aydin
- Department of IVF, Acıbadem University Atakent Hospital, Istanbul, Turkey
| | - Muberra Namli Kalem
- Department of IVF, Istinye University Liv Bahcesehir Hospital, Istanbul, Turkey
| | - Batuhan Bakirarar
- Department of Biostatistics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Elif Ganime Aygun
- Department of IVF, Acıbadem University Atakent Hospital, Istanbul, Turkey
| | - Ziya Kalem
- Department of IVF, Istinye University Liv Bahcesehir Hospital, Istanbul, Turkey
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Ye H, Shi L, Quan X, Xue X, Qian Y, Tian H, Xue S, Sun L. Frozen-thawed embryo transfer in modified natural cycles: a retrospective analysis of pregnancy outcomes in ovulatory women with vs. without spontaneous luteinizing hormone surge. BMC Pregnancy Childbirth 2022; 22:814. [PMCID: PMC9635083 DOI: 10.1186/s12884-022-05161-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 10/26/2022] [Indexed: 11/06/2022] Open
Abstract
Background Timing of frozen embryo transfer (FET) in natural endometrial preparation cycles is often based on luteinizing hormone (LH) surge. However, some patients do not show spontaneous LH surge despite follicular maturation. The objective of this study was to evaluate the impact of spontaneous LH surge on pregnancy outcomes in modified natural cycles (mNC). Methods This retrospective analysis included 1897 FET cycles with modified natural endometrial preparation in normo-ovulatory women between January 1, 2015, to December 31, 2019, at our center: 920 cycles with spontaneous LH surge (≥ 20 IU/L) and 977 without. For cleavage embryos, FET was conducted 4 and 5 days after hCG injection in women with and without LH surge, respectively. For blastocysts, FET was conducted 6 and 7 days after hCG injection in women with and without LH surge, respectively. Multivariate regression was conducted to examine the factors associated with live birth. Results Live birth rate was 43.7% in patients with spontaneous LH surge vs. 43.8% in women without LH surge (P = 0.961). The two groups also had similar implantation rate (36.2% vs. 36.7%, P = 0.772), biochemical pregnancy rate (54.8% vs. 55.4%, P = 0.796) and clinical pregnancy rate (50.9% vs. 51.7%, P = 0.721). In multivariate regression, live birth was not associated with LH surge (aOR, 0.947, 95% CI, 0.769, 1.166). Conclusion Pregnancy outcomes were similar in mNC-FET in cycles with vs. without spontaneous LH surge if FET timing is adjusted.
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Affiliation(s)
- Hongjuan Ye
- grid.24516.340000000123704535School of Life Sciences and Technology, Tongji University, Shanghai, China ,grid.24516.340000000123704535Department of Reproductive Medicine Center, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Liya Shi
- grid.24516.340000000123704535Department of Reproductive Medicine Center, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xinxin Quan
- grid.24516.340000000123704535Department of Reproductive Medicine Center, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xue Xue
- grid.24516.340000000123704535Department of Reproductive Medicine Center, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ying Qian
- grid.24516.340000000123704535Department of Reproductive Medicine Center, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hui Tian
- grid.24516.340000000123704535Department of Reproductive Medicine Center, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Songguo Xue
- grid.24516.340000000123704535Department of Reproductive Medicine Center, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lihua Sun
- grid.24516.340000000123704535Department of Reproductive Medicine Center, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
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Kadour-Peero E, Feferkorn I, Bellemare V, Arab S, Buckett W. A comparison of frozen-thawed embryo transfer protocols in 2920 single-blastocyst transfers. Arch Gynecol Obstet 2022; 306:887-892. [PMID: 35543740 DOI: 10.1007/s00404-022-06588-z] [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: 02/08/2022] [Accepted: 04/17/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the effect of frozen-thawed embryo transfer (FET) protocol on live-birth rate (LBR) and clinical pregnancy rate (CPR), in single-vitrified-blastocyst transfer MATERIALS AND METHODS: Retrospective cohort study with FET of a single-blastocyst embryos (n = 2920 cycles) thawed 2013-2018. FET protocols were natural cycles (NC-FET) (n = 147), artificial hormone replacement treatment cycles (HRT-FET) (n = 2645), and modified NC (mNC) with hCG triggering (n = 128). Primary outcome was LBR. Adjustment for age, embryo grade, year of freezing\thawing, infertility cause, and endometrial thickness was performed. RESULTS There were no significant differences between the groups with regard to female age, embryo grade, and endometrial thickness. LBR was higher in the mNC compared to HRT-FET cycles (38.3% vs. 20.9% P < 0.0001), and in the NC compared to HRT-FET cycles (34.7% vs. 20.9%, P = 0.0002). CPR was higher in the mNC compared to HRT-FET cycles (46.1% vs. 33.3% P = 0.0003), and in the NC compared to HRT-FET cycles (45.9% vs. 33.3%, P = 0.002). There was no significant difference in LBR or CPR between NC-FET and mNC-FET. Higher LBR with NC-FET and mNC-FET remained significant after adjusting for confounders (aOR 2.42, 95%CI 1.53-3.66, P < 0.0001). CONCLUSION The use of the convenient artificial HRT-FET cycles must be cautiously reconsidered in light of the potential negative effect on LBR when compared with natural cycle FET.
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Affiliation(s)
- Einav Kadour-Peero
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, McGill University, Montreal, QC, Canada.
| | - Ido Feferkorn
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, McGill University, Montreal, QC, Canada
| | - Veronique Bellemare
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, McGill University, Montreal, QC, Canada
| | - Suha Arab
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, McGill University, Montreal, QC, Canada
| | - William Buckett
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, McGill University, Montreal, QC, Canada
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11
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OUP accepted manuscript. Hum Reprod Update 2022; 28:717-732. [DOI: 10.1093/humupd/dmac012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/05/2022] [Indexed: 11/14/2022] Open
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12
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Lovrec VG, Kozar N, Reljic M. Outcome of vitrified-warmed blastocyst transfer performed on days 5–7 after urine LH detection. Reprod Biomed Online 2021; 44:630-635. [DOI: 10.1016/j.rbmo.2021.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/26/2021] [Accepted: 12/02/2021] [Indexed: 11/16/2022]
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Huang J, Lin J, Cai R, Lu X, Song N, Gao H, Kuang Y. Significance of endometrial thickness change after human chorionic gonadotrophin triggering in modified natural cycles for frozen-thawed embryo transfer. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1590. [PMID: 33437789 PMCID: PMC7791260 DOI: 10.21037/atm-20-1459] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background Peak endometrial thickness (EMT), measured on the end of follicular phase or early luteal phase, is the most widely used marker for endometrial receptivity during infertility treatment. However, the clinical significance of follicular-to-luteal EMT change remains unclear. We aimed to study whether the change of EMT between the day of human chorionic gonadotrophin (hCG) triggering and the day of frozen-thawed embryo transfer (FET) has any influence on pregnancy outcomes in modified natural cycles (mNCs). Methods This was a retrospective cohort study of 2,768 regular ovulatory women who underwent their first mNC-FET cycles from January 2011 to June 2015. Patients were divided into three groups according to the percentage change of EMT from the hCG triggering day to the FET day: >5% decrease (n=405), ±5% plateau (n=1,259) and >5% increase (n=1,104). The main outcome measure was live birth rate. Results Live birth rates were 41.9%, 39.8% [crude odds ratio (cOR) 0.91, 95% CI, 0.73–1.15) and 42.4% (cOR 1.02, 95% CI, 0.87–1.20) in the EMT plateau, decrease and increase groups, respectively (P=0.649). Multiple regression analysis did not alter the finding after controlling for a variety of confounders. Compared with the post-trigger EMT plateau group, the adjusted OR of live birth was 0.88 (95% CI, 0.69–1.12) in the decrease group and 1.05 (95% CI, 0.88–1.25) in the increase group. Similarly, no significant associations were observed before or after adjustment between EMT change and other pregnancy outcomes including positive hCG test, clinical pregnancy, early miscarriage and ongoing pregnancy. Conclusions EMT change from hCG triggering to embryo transfer was not associated with pregnancy chances in mNC-FET cycles. This reassuring finding should provide guidance for physicians and patients when confronted with EMT decrease on the transfer day.
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Affiliation(s)
- Jialyu Huang
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiaying Lin
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Renfei Cai
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xuefeng Lu
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ning Song
- Department of Histology, Embryology, Genetics and Developmental Biology, Shanghai Key Laboratory of Reproductive Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hongyuan Gao
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yanping Kuang
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Johal JK, Bavan B, Zhang W, Gardner RM, Lathi RB, Milki AA. The impact of timing modified natural cycle frozen embryo transfer based on spontaneous luteinizing hormone surge. J Assist Reprod Genet 2020; 38:219-225. [PMID: 33230616 DOI: 10.1007/s10815-020-01994-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 10/26/2020] [Indexed: 11/28/2022] Open
Abstract
PURPOSE To evaluate whether adjusting timing of modified natural cycle frozen embryo transfer (mNC-FET) 1 day earlier in the setting of a spontaneous LH surge has an impact on pregnancy outcomes. METHODS This retrospective cohort study evaluated all mNC-FET with euploid blastocysts from May 1, 2016 to March 30, 2019, at a single academic institution. Standard protocol for mNC-FET included ultrasound monitoring and hCG trigger when the dominant follicle and endometrial lining were appropriately developed. Patients had serum LH, estradiol, and progesterone checked on day of trigger. If LH was ≥ 20 mIU/mL, trigger was given that day and FET was performed 6 days after surge (LH/HCG+6), with the intent of transferring 5 days after ovulation. If LH was < 20 mIU/mL, FET was performed 7 days after trigger (hCG+7). Primary outcomes included clinical pregnancy and live birth rates. To account for correlation between cycles, a generalized estimating equation (GEE) method for multivariable logistic regression was used. RESULTS Four hundred fifty-three mNC-FET cycles met inclusion criteria, of which 205 were in the LH/HCG+6 group and 248 were in the HCG+7 group. The overall clinical pregnancy rate was 64% and clinical miscarriage rate was 4.8%, with similar rates between the two groups. The overall live birth rate was 60.9% (61.0% in LH/HCG+6 group and 60.9% in HCG+7 group). After implementing GEE, the odds of CP (aOR 0.97, 95% CI [0.65-1.45], p = 0.88) and LB (aOR 0.98, 95% CI [0.67-1.45], p = 0.93) were similar in both groups. CONCLUSIONS In our study cohort, mNC-FET based on LH/HCG+6 versus HCG+7 had similar pregnancy outcomes.
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Affiliation(s)
- J K Johal
- Department of Obstetrics & Gynecology, Stanford University, 300 Pasteur Drive, Palo Alto, CA, 94304, USA.
| | - B Bavan
- Division of Reproductive Endocrinology & Infertility Department of Obstetrics & Gynecology, Stanford University, 1195 West Fremont Avenue, MC 7717, Sunnyvale, CA, 94087, USA
| | - W Zhang
- Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
| | - R M Gardner
- Quantitative Sciences Unit, Stanford University School of Medicine, 1701 Page Mill Road, Palo Alto, CA, 94304, USA
| | - R B Lathi
- Division of Reproductive Endocrinology & Infertility Department of Obstetrics & Gynecology, Stanford University, 1195 West Fremont Avenue, MC 7717, Sunnyvale, CA, 94087, USA
| | - A A Milki
- Division of Reproductive Endocrinology & Infertility Department of Obstetrics & Gynecology, Stanford University, 1195 West Fremont Avenue, MC 7717, Sunnyvale, CA, 94087, USA
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15
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Is there a critical LH level for hCG trigger after the detection of LH surge in modified natural frozen-thawed single blastocyst transfer cycles? J Assist Reprod Genet 2020; 37:3025-3031. [PMID: 33057910 PMCID: PMC7714888 DOI: 10.1007/s10815-020-01974-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 10/07/2020] [Indexed: 11/24/2022] Open
Abstract
Purpose There is no consensus yet in the literature on an optimal luteinizing hormone (LH) level for human chorionic gonadotrophin (hCG) trigger timing in patients undergoing frozen-thawed embryo transfer (FET) with modified natural cycles (mNC). The objective of our study was to compare the clinical results of hCG trigger at different LH levels in mNC-FET cases. Methods This retrospective study was conducted in Istanbul Memorial Hospital ART and Genetics Center. A total of 1076 cases with 1163 mNC-FET cycles were evaluated. LH levels between the start of LH rise (15 IU/L) and LH peak level (> 40 IU/L) were evaluated. Cycles were analyzed in four groups: group A (n = 287) LH level on the day prior to the day of hCG; groups B, C and D, LH levels on the day of hCG: group B (n = 245) LH 15–24.9; group C (n = 253), LH 25–39.9; group D (n = 383) LH ≥ 40. Cycle outcomes in the four groups were compared. Results Subgroup analyses of mNC-FET groups showed that implantation, clinical and ongoing pregnancy rates, and pregnancy losses were not significantly different in patients with different LH levels on the day of hCG trigger. Conclusion Our study suggests that hCG can be administered at any time between the start of LH rise (≥ 15 IU/L) and LH peak level (≥ 40 IU/L) without a detrimental effect on clinical outcome.
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Park DS, Kim JW, Chang EM, Lee WS, Yoon TK, Lyu SW. Obstetric, Neonatal, and Clinical Outcomes of Day 6 vs. Day 5 Vitrified-Warmed Blastocyst Transfers: Retrospective Cohort Study With Propensity Score Matching. Front Endocrinol (Lausanne) 2020; 11:499. [PMID: 32849288 PMCID: PMC7418454 DOI: 10.3389/fendo.2020.00499] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 06/23/2020] [Indexed: 11/21/2022] Open
Abstract
Despite the large number of studies on blastocyst transfers, it is unclear whether day 6 blastocysts have similar pregnancy rates and safety with day 5 blastocysts. Thus, this study aimed to compare the obstetric, neonatal, and clinical outcomes of day 5 and day 6 vitrified blastocyst transfers (VBT). In this retrospective cohort study with propensity score matching, we evaluated 1,313 cycles of VBT performed between January 2014 and December 2015 at the Fertility Center of CHA Gangnam Medical Center. All cycles underwent natural endometrial preparation. We used propensity score matching to compare day 5 and day 6 VBTs in a matched comparison. After propensity score matching, there were 465 cycles of day 5 VBT and 155 cycles of day 6 VBT. Implantation rate (IR), clinical pregnancy rate (CPR), and live birth rate (LBR) were significantly lower in day 6 VBTs (44.2 vs. 53.1%, p = 0.023; 48.4 vs. 60.4%, p = 0.009; 33.5 vs. 51.8%, p < 0.001). Miscarriage rate was significantly higher in day 6 VBTs (29.3 vs. 10.7%, p < 0.001). Rate of multiple gestations was similar between the two groups (29.3 vs. 30.2%, p = 0.816). Assessing 241 and 52 babies from day 5 and day 6 VBTs, no differences were found in neonatal outcomes including rates of low birth weight, preterm birth, and congenital malformations. In propensity score-matched analysis, obstetric, and neonatal outcomes between day 5 and day 6 VBTs were similar so that day 6 VBTs are as safe as day 5 VBTs. IR, CPR, and LBR were are all significantly lower in day 6 VBTs. Therefore, if there are no differences in the morphological grade between day 5 and day 6 blastocysts, transfer of day 5 vitrified blastocysts should be considered first.
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Groenewoud ER, Cohlen BJ, Macklon NS. Programming the endometrium for deferred transfer of cryopreserved embryos: hormone replacement versus modified natural cycles. Fertil Steril 2018; 109:768-774. [DOI: 10.1016/j.fertnstert.2018.02.135] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 02/13/2018] [Accepted: 02/19/2018] [Indexed: 12/01/2022]
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HCG administration after endogenous LH rise negatively influences pregnancy rate in modified natural cycle for frozen-thawed euploid blastocyst transfer: a pilot study. J Assist Reprod Genet 2017; 35:449-455. [PMID: 29147846 DOI: 10.1007/s10815-017-1089-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 11/09/2017] [Indexed: 01/08/2023] Open
Abstract
PURPOSE The aim of the present study was to evaluate whether in a modified natural cycle (modified-NC) for a frozen-thawed single euploid blastocyst transfer, a critical LH value, above which human chorionic gonadotropin (hCG) administration should be avoided, may be defined. METHODS One hundred and sixty-seven patients underwent modified natural cycle in order to transfer a single frozen-thawed euploid blastocyst. All embryos were obtained by intracytoplasmic sperm injection and were biopsied at the blastocyst stage and analyzed by means of array comparative genomic hybridization (aCGH). Ovulation was induced using 10.000 IU hCG when the mean follicle diameter was at least of 17 mm, independently from LH values. The primary end points were the hCG-positive test and clinical pregnancy. The interim analysis showed that LH value ≥ 13 mIU/ml on the day of hCG injection may negatively influence the clinical results, suggesting that in this condition, it should be advisable waiting for spontaneous ovulation. RESULTS Among patients who received hCG for ovulation induction, the hCG-positive test and clinical pregnancy rates in modified-NC were significantly lower in cycles with LH ≥ 13 mIU/ml in respect to those with LH < 13 mIU/ml (45.4 vs 73.3 and 36.4 vs 65.9%, in LH ≥ 13 and LH < 13 groups, respectively). In patients with LH value ≥ 13 mIU/ml, hCG administration led to significantly lower rates of hCG-positive test (45.4 vs 74.5% in hCG administration and spontaneous ovulation groups, respectively) and clinical pregnancy (36.4 vs 64.7% in hCG administration and spontaneous ovulation groups, respectively). The baseline patient characteristics were comparable in all groups. CONCLUSIONS The findings of this study highlight that LH elevation ≥ 13 mIU/ml prior to hCG administration may negatively affect clinical pregnancy rates in modified-NC for single euploid blastocyst transfer. The LH determination should be routinely performed during follicular monitoring. In the presence of LH level ≥ 13 mIU/ml, hCG administration should be avoided, and the embryo transfer should be planned only after spontaneous follicular rupture.
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Mackens S, Santos-Ribeiro S, van de Vijver A, Racca A, Van Landuyt L, Tournaye H, Blockeel C. Frozen embryo transfer: a review on the optimal endometrial preparation and timing. Hum Reprod 2017; 32:2234-2242. [PMID: 29025055 DOI: 10.1093/humrep/dex285] [Citation(s) in RCA: 203] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Indexed: 01/24/2023] Open
Abstract
STUDY QUESTION What is the optimal endometrial preparation protocol for a frozen embryo transfer (FET)? SUMMARY ANSWER Although the optimal endometrial preparation protocol for FET needs further research and is yet to be determined, we propose a standardized timing strategy based on the current available evidence which could assist in the harmonization and comparability of clinic practice and future trials. WHAT IS KNOWN ALREADY Amid a continuous increase in the number of FET cycles, determining the optimal endometrial preparation protocol has become paramount to maximize ART success. In current daily practice, different FET preparation methods and timing strategies are used. STUDY DESIGN, SIZE, DURATION This is a review of the current literature on FET preparation methods, with special attention to the timing of the embryo transfer. PARTICIPANTS/MATERIALS, SETTING, METHODS Literature on the topic was retrieved in PubMed and references from relevant articles were investigated until June 2017. MAIN RESULTS AND THE ROLE OF CHANCE The number of high quality randomized controlled trials (RCTs) is scarce and, hence, the evidence for the best protocol for FET is poor. Future research should compare both the pregnancy and neonatal outcomes between HRT and true natural cycle (NC) FET. In terms of embryo transfer timing, we propose to start progesterone intake on the theoretical day of oocyte retrieval in HRT and to perform blastocyst transfer at hCG + 7 or LH + 6 in modified or true NC, respectively. LIMITATIONS REASONS FOR CAUTION As only a few high quality RCTs on the optimal preparation for FET are available in the existing literature, no definitive conclusion for benefit of one protocol over the other can be drawn so far. WIDER IMPLICATIONS OF THE FINDINGS Caution when using HRT for FET is warranted since the rate of early pregnancy loss is alarmingly high in some reports. STUDY FUNDING/COMPETING INTEREST(S) S.M. is funded by the Research Fund of Flanders (FWO). H.T. and C.B. report grants from Merck, Goodlife, Besins and Abbott during the conduct of the study. TRIAL REGISTRATION NUMBER Not applicable.
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Affiliation(s)
- S Mackens
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101-1090 Brussels, Belgium
| | - S Santos-Ribeiro
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101-1090 Brussels, Belgium.,Department of Obstetrics, Gynaecology and Reproductive Medicine, Santa Maria University Hospital, Avenida Professor Egas Moniz, Lisbon 1649-035, Portugal
| | - A van de Vijver
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101-1090 Brussels, Belgium
| | - A Racca
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101-1090 Brussels, Belgium.,Academic Unit of Obstetrics and Gynecology, IRCCS AOU San Martino-IST, University of Genova, Largo R. Benzi 10, 16132 Genova, Italy
| | - L Van Landuyt
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101-1090 Brussels, Belgium
| | - H Tournaye
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101-1090 Brussels, Belgium
| | - C Blockeel
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101-1090 Brussels, Belgium.,Department of Obstetrics and Gynaecology, School of Medicine, University of Zagreb, Petrova 13, 10000 Zagreb, Croatia
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The effect of elevated progesterone levels before HCG triggering in modified natural cycle frozen-thawed embryo transfer cycles. Reprod Biomed Online 2017; 34:546-554. [DOI: 10.1016/j.rbmo.2017.02.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 02/09/2017] [Accepted: 02/14/2017] [Indexed: 12/17/2022]
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21
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Groenewoud E, Macklon N, Cohlen B. Reply: Perspectives on results from cryopreservation/thawing cycles. Hum Reprod 2016; 31:2894-2895. [DOI: 10.1093/humrep/dew257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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22
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Kalem Z, Kalem MN, Gürgan T. Methods for endometrial preparation in frozen-thawed embryo transfer cycles. J Turk Ger Gynecol Assoc 2016; 17:168-72. [PMID: 27651727 PMCID: PMC5019835 DOI: 10.5152/jtgga.2016.15214] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 07/14/2016] [Indexed: 11/22/2022] Open
Abstract
Frozen-thawed (FT) embryo transfer is a procedure used for the storage and transfer of excess embryos obtained during in vitro fertilization- intracytoplasmic sperm injection cycles. In recent years, improvements in laboratory conditions and limitations on the number of embryos to be transferred have led to a progressive increase in FT embryo transfer cycles. However, the best solution for endometrial preparation in these cycles is still a matter of debate. In this study, we aimed to review the current methods of endometrial preparation in FT embryo transfer cycles. In light of the current literature, it is hard to determine which method is the best for endometrial preparation. It is therefore necessary to conduct randomized controlled studies in a prospective design, which will also evaluate the above-mentioned factors.
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Affiliation(s)
- Ziya Kalem
- Gürgan Clinic IVF Center, Ankara, Turkey
| | - Müberra Namlı Kalem
- Department of Obstetrics and Gynecologoy, Turgut Özal University School of Medicine, Ankara, Turkey
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Yarali H, Polat M, Mumusoglu S, Yarali I, Bozdag G. Preparation of endometrium for frozen embryo replacement cycles: a systematic review and meta-analysis. J Assist Reprod Genet 2016; 33:1287-1304. [PMID: 27549760 DOI: 10.1007/s10815-016-0787-0] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 07/29/2016] [Indexed: 11/30/2022] Open
Abstract
PURPOSE The purpose of this study was to evaluate the best protocol to prepare endometrium for frozen embryo replacement (FER) cycles. METHODS This study is a systematic review and meta-analysis. Following PubMed and OvidSP search, a total of 1166 studies published after 1990 were identified following removal of duplicates. Following exclusion of studies not matching our inclusion criteria, a total of 33 studies were analyzed. Primary outcome measure was live birth. The following protocols, including true natural cycle (tNC), modified natural cycle (mNC), artificial cycle (AC) with or without suppression, and mild ovarian stimulation (OS) with gonadotropin (Gn) or aromatase inhibitor (AI), were compared. RESULTS No statistically significant difference for both clinical pregnancy and live birth was noted between tNC and mNC groups. When tNC and AC without suppression groups are compared, there was a statistically significant difference in clinical pregnancy rate in favor of tNC, whereas it failed to reach statistical significance for live birth. When tNC and AC with suppression groups are compared, there was a statistically significant difference in live birth rate favoring the latter. Similar pregnancy outcome was noted among mNC versus AC with or without suppression groups. Similarly, no difference in clinical pregnancy and live birth was noted when ACs with or without suppression groups are compared. CONCLUSIONS There is no consistent superiority of any endometrial preparation for FER. However, mNC has several advantages (being patient-friendly; yielding at least equivalent or better pregnancy rates when compared with tNC and AC with or without suppression; may not require LPS). Mild OS with Gn or AI may be promising.
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Affiliation(s)
- Hakan Yarali
- Department of Obstetric and Gynecology, Hacettepe University School of Medicine, 06100, Ankara, Turkey. .,Anatolia IVF and Women Health Centre, Ankara, Turkey.
| | - Mehtap Polat
- Anatolia IVF and Women Health Centre, Ankara, Turkey
| | - Sezcan Mumusoglu
- Department of Obstetric and Gynecology, Hacettepe University School of Medicine, 06100, Ankara, Turkey
| | - Irem Yarali
- Anatolia IVF and Women Health Centre, Ankara, Turkey
| | - Gurkan Bozdag
- Department of Obstetric and Gynecology, Hacettepe University School of Medicine, 06100, Ankara, Turkey
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Groenewoud ER, Cohlen BJ, Al-Oraiby A, Brinkhuis EA, Broekmans FJM, de Bruin JP, van den Dool G, Fleisher K, Friederich J, Goddijn M, Hoek A, Hoozemans DA, Kaaijk EM, Koks CAM, Laven JSE, van der Linden PJQ, Manger AP, Slappendel E, Spinder T, Kollen BJ, Macklon NS. A randomized controlled, non-inferiority trial of modified natural versus artificial cycle for cryo-thawed embryo transfer. Hum Reprod 2016; 31:1483-92. [PMID: 27179265 PMCID: PMC5853593 DOI: 10.1093/humrep/dew120] [Citation(s) in RCA: 137] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 03/24/2016] [Accepted: 04/26/2016] [Indexed: 12/23/2022] Open
Abstract
STUDY QUESTION Are live birth rates (LBRs) after artificial cycle frozen-thawed embryo transfer (AC-FET) non-inferior to LBRs after modified natural cycle frozen-thawed embryo transfer (mNC-FET)? SUMMARY ANSWER AC-FET is non-inferior to mNC-FET with regard to LBRs, clinical and ongoing pregnancy rates (OPRs) but AC-FET does result in higher cancellation rates. WHAT IS ALREADY KNOWN Pooling prior retrospective studies of AC-FET and mNC-FET results in comparable pregnancy and LBRs. However, these results have not yet been confirmed by a prospective randomized trial. STUDY DESIGN, SIZE AND DURATION In this non-inferiority prospective randomized controlled trial (acronym 'ANTARCTICA' trial), conducted from February 2009 to April 2014, 1032 patients were included of which 959 were available for analysis. The primary outcome of the study was live birth. Secondary outcomes were clinical and ongoing pregnancy, cycle cancellation and endometrium thickness. A cost-efficiency analysis was performed. PARTICIPANT/MATERIALS, SETTING, METHODS This study was conducted in both secondary and tertiary fertility centres in the Netherlands. Patients included in this study had to be 18-40 years old, had to have a regular menstruation cycle between 26 and 35 days and frozen-thawed embryos to be transferred had to derive from one of the first three IVF or IVF-ICSI treatment cycles. Patients with a uterine anomaly, a contraindication for one of the prescribed medications in this study or patients undergoing a donor gamete procedure were excluded from participation. Patients were randomized based on a 1:1 allocation to either one cycle of mNC-FET or AC-FET. All embryos were cryopreserved using a slow-freeze technique. MAIN RESULTS AND THE ROLE OF CHANCE LBR after mNC-FET was 11.5% (57/495) versus 8.8% in AC-FET (41/464) resulting in an absolute difference in LBR of -0.027 in favour of mNC-FET (95% confidence interval (CI) -0.065-0.012; P = 0.171). Clinical pregnancy occurred in 94/495 (19.0%) patients in mNC-FET versus 75/464 (16.0%) patients in AC-FET (odds ratio (OR) 0.8, 95% CI 0.6-1.1, P = 0.25). 57/495 (11.5%) mNC-FET resulted in ongoing pregnancy versus 45/464 (9.6%) AC-FET (OR 0.7, 95% CI 0.5-1.1, P = 0.15). χ(2) test confirmed the lack of superiority. Significantly more cycles were cancelled in AC-FET (124/464 versus 101/495, OR 1.4, 95% CI 1.1-1.9, P = 0.02). The costs of each of the endometrial preparation methods were comparable (€617.50 per cycle in NC-FET versus €625.73 per cycle in AC-FET, P = 0.54). LIMITATIONS, REASONS FOR CAUTION The minimum of 1150 patients required for adequate statistical power was not achieved. Moreover, LBRs were lower than anticipated in the sample size calculation. WIDER IMPLICATIONS OF THE FINDINGS LBRs after AC-FET were not inferior to those achieved by mNC-FET. No significant differences in clinical and OPR were observed. The costs of both treatment approaches were comparable. STUDY FUNDING/COMPETING INTERESTS An educational grant was received during the conduct of this study. Merck Sharpe Dohme had no influence on the design, execution and analyses of this study. E.R.G. received an education grant by Merck Sharpe Dohme (MSD) during the conduct of the present study. B.J.C. reports grants from MSD during the conduct of the study. A.H. reports grants from MSD and Ferring BV the Netherlands and personal fees from MSD. Grants from ZonMW, the Dutch Organization for Health Research and Development. J.S.E.L. reports grants from Ferring, MSD, Organon, Merck Serono and Schering-Plough during the conduct of the study. F.J.M.B. receives monetary compensation as member of the external advisory board for Merck Serono, consultancy work for Gedeon Richter, educational activities for Ferring BV, research cooperation with Ansh Labs and a strategic cooperation with Roche on automated anti Mullerian hormone assay development. N.S.M. reports receiving monetary compensations for external advisory and speaking work for Ferring BV, MSD, Anecova and Merck Serono during the conduct of the study. All reported competing interests are outside the submitted work. No other relationships or activities that could appear to have influenced the submitted work. TRIAL REGISTRATION NUMBER Netherlands trial register, number NTR 1586. TRIAL REGISTRATION DATE 13 January 2009. FIRST PATIENT INCLUDED 20 April 2009.
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Affiliation(s)
- E R Groenewoud
- Department of Obstetrics and Gynecology, Leeuwarden Medical Centre, PO Box 888, 8901 HR Leeuwarden, The Netherlands
| | - B J Cohlen
- Isala Fertility Centre, Isala Clinics, PO Box 10400, 8000 GK Zwolle, The Netherlands
| | - A Al-Oraiby
- Department of Obstetrics and Gynaecology, Amphia Hospital, PO Box 90157, 4800 RL Breda, The Netherlands
| | - E A Brinkhuis
- Department of Obstetrics and Gynecology, Meander Medical Center, Postbus 1502, 3800 BM Amersfoort, The Netherlands
| | - F J M Broekmans
- Department for Reproductive Medicine, University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - J P de Bruin
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, PO Box 90153, 5200 ME 's-Hertogenbosch, The Netherlands
| | - G van den Dool
- Department of Obstetrics and Gynaecology, Albert Schweitzer Hospital, PO Box 444, 3300 AK Dordrecht, The Netherlands
| | - K Fleisher
- Department of Obstetrics and Gynecology, University Medical Center Nijmegen, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - J Friederich
- Department of Obstetrics and Gynecology, Noordwest Ziekenhuisgroep, PO Box 750, 1782 GZ Den Helder, The Netherlands
| | - M Goddijn
- Centre for Reproductive Medicine, Academic Medical Centre, University of Amsterdam, PO Box 22600, 1100 DD Amsterdam, The Netherlands
| | - A Hoek
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Centre Groningen, PO Box 30001, 9700 RB Groningen, The Netherlands
| | - D A Hoozemans
- Department of Obstetrics and Gynaecology, Medical Spectrum Twente, PO Box 50000, 7500 KA Enschede, The Netherlands
| | - E M Kaaijk
- Department of Obstetrics and Gynaecology, Onze Lieve Vrouwe Gasthuis, PO Box 95500, 1090 HM Amsterdam, The Netherlands
| | - C A M Koks
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, PO Box 7777, 5500 MB Veldhoven, The Netherlands
| | - J S E Laven
- Department of Obstetrics and Gynecology, Erasmus Medical Centre Rotterdam, Postbus 2040, 3000 CA Rotterdam, The Netherlands
| | - P J Q van der Linden
- Department of Obstetrics and Gynecology, Deventer Hospital, PO Box 5001, 7400 GC Deventer, The Netherlands
| | - A P Manger
- Department of Obstetrics and Gynecology, Diakonessenhuis, PO Box 80250, 3508 TG Utrecht, The Netherlands
| | - E Slappendel
- Department of Obstetrics and Gynaecology, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, The Netherlands
| | - T Spinder
- Department of Obstetrics and Gynecology, Leeuwarden Medical Centre, PO Box 888, 8901 HR Leeuwarden, The Netherlands
| | - B J Kollen
- Department of General Practice, University of Groningen, University Medical Centre Groningen, PO Box 30001, 9700 RB Groningen, The Netherlands
| | - N S Macklon
- Department of Obstetrics and Gynecology, Academic Unit of Human Development and Health, University of Southampton, University Road, Southampton SO17 1BJ, UK
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What is the optimal means of preparing the endometrium in frozen–thawed embryo transfer cycles? A systematic review and meta-analysis. Hum Reprod Update 2013; 19:458-70. [DOI: 10.1093/humupd/dmt030] [Citation(s) in RCA: 183] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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