The effect of follicular phase length on cycle outcomes and endometrial development in gonadotrophin ovarian stimulation/intrauterine insemination cycles

Follicular phase length is not related to live birth outcome in women with unexplained infertility undergoing ovarian stimulation with intrauterine insemination cycles in a multicenter trial

Objective

To evaluate the effect of follicular phase length (FPL) on pregnancy outcomes and endometrial thickness (ET) among women with unexplained infertility undergoing ovarian stimulation with intrauterine insemination (OS-IUI) with clomiphene citrate, letrozole, or gonadotropins.

Design

Cohort analysis of the Reproductive Medicine Network's Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation randomized controlled trial.

Setting

Multicenter randomized controlled trial.

Patients

A total of 869 couples with unexplained infertility who underwent OS-IUI treatment cycles as part of the Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation study.

Interventions

FPL was evaluated as a categorical variable defined by quintiles (q1: ≤11 days, q2: 12 days, q3: 13 days, q4: 14-15 days, and q5: ≥16 days).

Main outcome measures

Clinical pregnancy, live birth rates, and ET.

Results

Decreasing FPL quintiles did not reduce clinical pregnancy or live birth rates in unadjusted or adjusted models with all treatment groups combined or when stratified by the ovarian stimulation medication. All FPL categories had significantly thinner ET compared with the 5th quintile (≥16 days) among women treated with clomiphene citrate or letrozole. Similar but diminished associations were observed among women who underwent ovarian stimulation with gonadotropins, but the observed differences were limited to those with FPL of 12 days or shorter when compared with FPL ≥16 days.

Conclusions

Although shorter FPL was associated with reduced ET, it was not associated with the outcomes of clinical pregnancy or live birth in women with unexplained infertility undergoing OS-IUI in all treatment groups combined. Similar patterns existed when analyses of clinical pregnancy and live birth rates were stratified by treatment.

Clinical trial registration

NCT01044862.

Factors associated with spontaneous miscarriage risk in IUI treatment: A retrospectively cohort of 31,933 cycles

To determine the factors associated with intrauterine insemination (IUI) miscarriages and reduce the IUI miscarriage rate, a retrospective study was performed by reviewing 31,933 IUI cycles from 2006 to 2018. The overall there were 14.50% clinical pregnancies, and 16.74% miscarriages. Logistic regression revealed the following three predictive variables: females aged ≥ 35 years (odds ratio [OR] = 2.131; p < 0.001), spontaneous miscarriage history (OR = 1.513; p = 0.005), and ovarian stimulation schemes such as clomiphene citrate (CC) (OR = 1.459; p = 0.003). The natural cycle led to a lower miscarriage rate for patients without spontaneous miscarriage history both for those over 35 years old (OR = 0.402; p = 0.034) and for those under 35 years old (OR = 0.806; p = 0.017). Gonadotropin (Gn) showed the lowest miscarriage rate for patients without abortion history, though no significant differences were found. Patients under 35 with a history of miscarriage were protected from miscarriage by using CC and Gn together (OR = 0.516; p = 0.032). No significant differences were found between various ovarian protocols when patients with abortion history were aged ≥ 35 years (p = 0.606). CC + Gn showed the lowest miscarriage rate. In conclusion, the natural cycle could be suggested for infertility couples to minimize abortion risk. When ovarian induction is required, CC + Gn had the lowest miscarriage rate for women with a history of spontaneous miscarriage while Gn is more successful for individuals without such a history.

The impact of anti-Müllerian hormone on endometrial thickness in gonadotropin stimulation/intrauterine insemination cycles: is there an effect on pregnancy outcomes?

PURPOSE

To study the association, if any, between anti-Müllerian hormone (AMH) and pre-ovulatory endometrial thickness (ET) in gonadotropin/intrauterine insemination (IUI) cycles.

METHODS

This retrospective cohort study included a total of 964 patients undergoing 1926 gonadotropin/IUI cycles at an academic fertility center. Primary outcome measure was the association between serum AMH and measured ET on the day of and the day before human chorionic gonadotropin hormone (hCG) ovulation trigger. The effect of a model combining AMH and ET on early pregnancy outcomes was a secondary measure.

RESULTS

In 52.8% of cycles, ET was last assessed and recorded on the day of hCG administration, while in the remaining 47.2% on the day prior to trigger. In unadjusted regression models, AMH was weakly correlated with ET on hCG trigger day [bAMH (95%CI) = 0.032 (- 0.008, 0.070), p = 0.015]. When adjusting for potential confounders, the positive correlation became significant [0.051 (0.006, 0.102), p = 0.047]. Similar findings were observed when assessing the correlation between AMH and ET on the day prior to hCG trigger. ET was non-significantly associated with the odds of clinical pregnancy, when adjusting for potential confounders, except for when restricting the analysis to couples with idiopathic infertility [OR (95%CI), p-value: 0.787 (0.623, 0.993), 0.044].

CONCLUSION

Our findings support an effect of serum AMH on endometrial development in gonadotropin induced cycles, even when adjusting for the diagnosis of PCOS. ET was not associated with the odds of achieving a clinical pregnancy, except for couples with idiopathic infertility.

Investigation of the role of X chromosome inactivation and androgen receptor CAG repeat polymorphisms in patients with recurrent pregnancy loss: a prospective case-control study

BACKGROUND

Previous research has revealed that skewed X chromosome inactivation (SXCI) and androgen receptor (AR) CAG polymorphisms are associated with increased risk of recurrent pregnancy loss (RPL); however, the results are conflicting, and the underlying mechanisms remain unclear. This study investigated the role of SXCI and AR CAG polymorphisms in patients with RPL and explored whether the underlying mechanisms were related to the ovarian reserve and preimplantation embryo aneuploidy.

METHODS

This was a prospective case-control study carried out in a tertiary hospital-based reproductive medicine center. An external validation RPL cohort was recruited during the study period. Data on baseline and cycle characteristics were collected. X-chromosome inactivation (XCI) was measured using a human AR assay. AR polymorphisms were assessed using quantitative fluorescent polymerase chain reactions and direct sequencing. Blastocysts of the patients with RPL were tested by single nucleotide polymorphism microarray based preimplantation genetic testing for aneuploidy.

RESULTS

In total, 131 patients with idiopathic RPL and 126 controls were included for the case-control study. Patients with RPL exhibited a significantly more skewed XCI distribution pattern (67.71 ± 10.50 vs. 64.22 ± 10.62, p = 0.011), as well as significantly shorter bi-allelic mean (18.56 ± 1.97 vs. 19.34 ± 2.38, p = 0.005) and X-weighted bi-allelic mean (18.46 ± 2.02 vs. 19.38 ± 2.53, p = 0.001) of AR CAG repeats. Multivariate logistic regression models indicated that CAG repeat < 20, SXCI, and duration of stimulation were independently associated with the risk of RPL. However, SXCI and AR CAG polymorphisms were not associated with ovarian reserve or preimplantation embryo aneuploidy in the RPL group, and the same results were attained in a separate validation cohort of 363 patients with RPL.

CONCLUSION

SXCI and AR CAG polymorphisms are related to RPL; however, these two factors do not lead to RPL by affecting the ovarian reserve or increasing embryo aneuploidy. The roles of SXCI and AR CAG in RPL may involve other mechanisms that require further investigation.

TRIAL REGISTRATION

NCT02504281, https://www.

CLINICALTRIALS

gov (Date of registration, 21/07/2015; date of enrolment of the first subject, 30/07/2015).

Association Between the Ratio of Ovarian Stimulation Duration to Original Follicular Phase Length and In Vitro Fertilization Outcomes: A Novel Index to Optimise Clinical Trigger Time

The duration of ovarian stimulation which is largely dependent on the ovarian response to hormonal stimulation may influence in vitro fertilization (IVF) outcomes. Menstrual cycle length is potentially a good indicator of ovarian reserve and can predict ovarian response. Ovarian stimulation and the follicular phase of the menstrual cycle are both processes of follicular development. There is no published research to predict the duration of ovarian stimulation based on the length of the menstrual cycle. Our retrospective cohort study included 6110 women with regular menstrual cycles who underwent their first IVF treatment between January 2015 and October 2020. Cycles were classified according to quartiles of the ratio of ovarian stimulation duration to original follicular phase length (OS/FP). Multivariate generalized linear models were applied to assess the association between OS/FP and IVF outcomes. The odds ratio (OR) or relative risk (RR) was estimated for each quartile with the lowest quartile as the comparison group. OS/FP of 0.67 to 0.77 had more retrieved and mature oocytes (adjusted RR 1.11, 95% confidence interval [CI] 1.07-1.15, p for trend = 0.001; adjusted RR 1.14, 95% CI 1.09-1.19, p for trend = 0.001). OS/FP of 0.67 to 0.77 showed the highest rate of fertilization (adjusted OR 1.11, 95% CI 1.05-1.17, p for trend = 0.001). OS/FP > 0.77 had the lowest rate of high-quality blastocyst formation (adjusted OR 0.81, 95% CI 0.71-0.93, p for trend = 0.01). No apparent association was noted between OS/FP and clinical pregnancy, live birth, or early miscarriage rate. In conclusion, OS/FP has a significant effect on the number of oocytes, fertilization rate, and high-quality blastocyst formation rate. MCL could be used to predict the duration of ovarian stimulation with an OS/FP of 0.67 to 0.77, which provides a new indicator for the individualized clinical optimization of the trigger time.

The efficiency of low-dose letrozole plus clomiphene citrate for ovulation induction in intrauterine insemination cycles: A randomized clinical trial

OBJECTIVE

To investigate if combination therapy with clomiphene citrate (CC) plus letrozole (L) was associated with a higher efficacy than L and CC alone in patients undergoing ovarian induction plus intrauterine insemination.

METHODS

The present multicenter randomized controlled clinical trial was performed between 2018 and 2020. Participants were randomized into three groups: L (n = 167; 5 mg/day), CC (n = 167; 100 mg/day), and L + CC (n = 167) (2.5 mg/day + 50 mg/day) from day 3. Ovarian stimulation was continued with the appropriate dose of gonadotropins daily starting from day 8 and continued until follicular size was 20 mm or more followed by administration of human chorionic gonadotropin (10 000 IU). Semen samples were prepared by direct swim-up technique.

RESULTS

In the CC group, gonadotropin dose was significantly higher but endometrial thickness was significantly lower compared with other groups. Number of follicles of 18 mm or more was significantly lower in the L group compared with the other two groups. Number of follicles less than 15 mm was meaningfully higher in the CC group compared with the other groups. In the L + CC group, total and largest follicular size, and the rates of chemical, clinical, and ongoing pregnancy, and live birth were significantly higher compared with other groups.

CONCLUSION

Combination therapy with L + CC was superior to either L or CC for achieving pregnancy in women undergoing ovarian induction plus intrauterine insemination.