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Berdin A, Bellaïche K, El Hachem H, Vielle B, Legendre G, Descamps P, May-Panloup P, Prevost S, Bouet PE. Comparison of two cancellation strategies to lower the risk of multiple pregnancies in gonadotropin stimulated intrauterine insemination cycles. Int J Gynaecol Obstet 2024; 166:692-698. [PMID: 38425230 DOI: 10.1002/ijgo.15449] [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: 10/05/2023] [Revised: 01/09/2024] [Accepted: 02/12/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVE To compare two cancellation policies in controlled ovarian stimulation-intrauterine insemination (COS-IUI) cycles to lower the risk of multiple pregnancies (MP). DESIGN We performed a bicentric retrospective cohort study in two academic medical centers: Angers (group A) and Besançon (group B) University Hospitals. We included 7056 COS-IUI cycles between 2011 and 2019. In group A, cancellation strategy was based on an algorithm taking into account the woman's age, the serum estradiol level, and the number of follicles of 14 mm or greater on ovulation trigger day. In group B, cancellation strategy was case-by-case and physician-dependent, based on the woman's age, number of follicles of 15 mm or greater, and the previous number of failed COS-IUI cycles, without any predefined cut-off. Our main outcome measures were the MP rate (MPR) and the live-birth rate (LBR). RESULTS We included 884 clinical pregnancies (790 singletons, 86 twins, and 8 triplets) obtained from 6582 COS-IUI cycles. MPR was significantly lower in group A compared with group B (8.1% vs 13.3%, P = 0.01), but LBR were comparable (10.8% vs 11.8%, P = 0.19). Multivariate logistic regression found the following to be risk factors for MP: the "cancellation strategy" effect (adjusted odds ratio [aOR] 1.63, 95% confidence interval [CI] 1.02-2.60) and the number of follicles of 14 mm or greater (aOR 1.39, 95% CI 1.16-1.66). Cycle cancellation rate for excessive response was significantly lower in group A compared with group B (1.3% vs 2.4%, P < 0.001). CONCLUSIONS The use of an algorithm based on the woman's age, serum estradiol level and number of follicles of at least 14 mm on trigger day allows the MPR to be reduced without impacting the LBR.
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Affiliation(s)
- Aurélie Berdin
- Department of Reproductive Medicine, Besançon University Hospital, Besançon, France
| | - Kevin Bellaïche
- Department of Reproductive Medicine, Angers University Hospital, Angers, France
| | - Hady El Hachem
- Department of Obstetrics and Gynecology, Lebanese American University Medical Center, Beirut, Lebanon
| | - Bruno Vielle
- Clinical Research Center, Angers University Hospital, Angers, France
| | - Guillaume Legendre
- Department of Reproductive Medicine, Angers University Hospital, Angers, France
| | - Philippe Descamps
- Department of Reproductive Medicine, Angers University Hospital, Angers, France
| | - Pascale May-Panloup
- Department of Reproductive Medicine, Angers University Hospital, Angers, France
| | - Sarah Prevost
- Department of Reproductive Medicine, Besançon University Hospital, Besançon, France
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Mandelbaum RS, Agarwal R, Melville S, Violette CJ, Winer S, Shoupe D, Matsuo K, Paulson RJ, Quinn MM. A comparison of letrozole regimens for ovulation induction in women with polycystic ovary syndrome. F S Rep 2024; 5:170-175. [PMID: 38983726 PMCID: PMC11228783 DOI: 10.1016/j.xfre.2024.03.004] [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: 10/26/2023] [Revised: 03/22/2024] [Accepted: 03/25/2024] [Indexed: 07/11/2024] Open
Abstract
Objective To determine the optimal letrozole regimen for ovulation induction (OI) in women with polycystic ovary syndrome (PCOS). Design Retrospective cohort study. Setting Single academic fertility clinic from 2015-2022. Patients A total of 189 OI cycles in 52 patients with PCOS. Interventions Patients were prescribed 1 of 4 letrozole regimens (group 1: 2.5 mg for 5 days, group 2: 2.5 mg for 10 days, group 3: 5 mg for 5 days, and group 4: 5 mg for 10 days). Main outcome measures The primary outcome was ovulation, and secondary outcomes included multifollicular development, and clinical pregnancy rate, which were analyzed with binary logistic regression. Kaplan-Meier cumulative response curves and a Cox proportional hazard regression model were used for time-dependent analyses. Results Mean age was 30.9 years (standard deviation [SD], 3.6) and body mass index was 32.1 kg/m2 (SD, 4.0). Group 2 (odds ratio [OR], 9.12; 95% confidence interval [CI], 1.92-43.25), group 3 (OR, 3.40; 95% CI, 1.57-7.37), and group 4 (OR, 5.94; 95% CI, 2.48-14.23) had improved ovulation rates after the starting regimen as compared with group 1. Cumulative ovulation rates exceeded 84% in all groups, yet those who received 5 mg and/or 10 days achieved ovulation significantly sooner. Multifollicular development was not increased in groups 2-4 as compared with group 1. Groups 2-4 also demonstrated improved time to pregnancy. Conclusions Ovulation rates are improved when starting with letrozole at 5 mg and/or a 10-day extended course as compared with the frequently-used 2.5 mg for 5 days. This may shorten time to ovulation and pregnancy.
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Affiliation(s)
- Rachel S Mandelbaum
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Ravi Agarwal
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Samuel Melville
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Caroline J Violette
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Sharon Winer
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Donna Shoupe
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California
| | - Richard J Paulson
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Molly M Quinn
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Southern California Keck School of Medicine, Los Angeles, California
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Vyrides AA, El Mahdi E, Giannakou K. Ovulation induction techniques in women with polycystic ovary syndrome. Front Med (Lausanne) 2022; 9:982230. [PMID: 36035398 PMCID: PMC9411864 DOI: 10.3389/fmed.2022.982230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
Anovulation is very common and has several different clinical manifestations, including amenorrhea, oligomenorrhea and abnormal uterine bleeding. Various mechanisms can cause anovulation. The clinical consequences and commonest chronic anovulatory disorder, polycystic ovary syndrome (PCOS), has a prevalence that ranges between 6 to 10% of the global population. While multiple causes can eventually result in PCOS, various methods have been described in the literature for its management, often without ascertaining the underlying cause. Ovulation Induction (OI) is a group of techniques that is used in women with PCOS who are looking to conceive and are unbale to do so with natural means. This narrative review presents a summary of the current evidence and available techniques for OI in women with PCOS, highlighting their performance and applicability.
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Affiliation(s)
- Andreas A. Vyrides
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Essam El Mahdi
- Department of Obstetrics and Gynecology, Newham University Hospital NHS Trust, London, United Kingdom
| | - Konstantinos Giannakou
- Department of Health Sciences, School of Sciences, European University Cyprus, Nicosia, Cyprus
- *Correspondence: Konstantinos Giannakou
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Comparison of congenital malformations among babies born after administration of letrozole or clomiphene citrate for infertility treatment in a Korean cohort. Reprod Toxicol 2018; 82:88-93. [DOI: 10.1016/j.reprotox.2018.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 10/07/2018] [Accepted: 10/12/2018] [Indexed: 01/22/2023]
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Could fetal reduction induce facial cleft? Report of a case. Br J Oral Maxillofac Surg 2018; 56:543-545. [PMID: 29859779 DOI: 10.1016/j.bjoms.2018.05.009] [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: 02/21/2018] [Accepted: 05/15/2018] [Indexed: 11/22/2022]
Abstract
We describe a paramedian cleft of the lower lip that cannot be explained by embryological development in a child with only one predisposing factor, which was fetal reduction for a multiple pregnancy. To the best of our knowledge, there has been no report of a cleft that has been induced by the reduction of a multifetal pregnancy.
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Abstract
The menstrual cycle is a reproductive vital sign and provides insight into hormonal imbalance as well as pregnancy. The significance of estrogen, however, extends beyond fertility and plays a role on tissues and organs throughout the body. Functional hypothalamic amenorrhea is a common form of secondary amenorrhea resulting in estrogen deficiency in young premenopausal women. While reversible, the cause of this disorder is related to psychological stress, excessive exercise, disordered eating or a combination of these factors resulting in suppression of the hypothalamic–pituitary–ovarian axis. The resulting loss of estrogen has profound effects on many systems throughout the body including cardiac, skeletal, psychological and reproductive. Often, these young women are the ‘walking well’ as they do not have bothersome symptoms of low estrogen and are unaware of the consequences of estrogen deficiency. This review focuses on the health consequences of hypothalamic amenorrhea, current research and available treatment options.
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Affiliation(s)
- Chrisandra L Shufelt
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Tina Torbati
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Erika Dutra
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
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Ovulation rate and cycle characteristics in a subsequent clomiphene citrate cycle after stair-step protocol. Fertil Steril 2015; 103:675-9. [DOI: 10.1016/j.fertnstert.2014.12.088] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 11/27/2014] [Accepted: 12/03/2014] [Indexed: 11/23/2022]
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Abstract
The purpose of this paper is to provide a stepwise approach to treating the infertility/subfertility associated with polycystic ovary syndrome. Defining polycystic ovary syndrome in a patient requires first investigating other possible causes for polycystic ovary morphology, acne, hirsutism, obesity, and the metabolic derangements that often accompany polycystic ovary syndrome. Beginning with lifestyle modification and use of metformin, the progressive inclusion of more intensive therapies for induction of ovulation is described. Second-line treatments are discussed and the new findings from a large multicenter trial are discussed in the context of evidence-based treatment strategies for first-line agents. Finally, monofollicular development as a treatment goal and in vitro fertilization are discussed for those with recalcitrant disease.
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Affiliation(s)
- Joshua J Berger
- University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Birmingham, AL, USA
| | - G Wright Bates
- University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Birmingham, AL, USA
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Moolenaar LM, Nahuis MJ, Hompes PG, van der Veen F, Mol BWJ. Cost-effectiveness of treatment strategies in women with PCOS who do not conceive after six cycles of clomiphene citrate. Reprod Biomed Online 2014; 28:606-13. [DOI: 10.1016/j.rbmo.2014.01.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Revised: 01/15/2014] [Accepted: 01/22/2014] [Indexed: 10/25/2022]
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Abstract
OBJECTIVES To describe trends in twin maternity rates, factors which contribute to these trends, and risks associated with twin maternities for mothers and children. POPULATION AND METHOD The review was done on population-based studies, preferably in France and the European Union. RESULTS The rate of twin maternities was 15.6 p 1000 in 2008 and it increased by about 80% between 1972 and 2006. This rise was explained mainly by advanced maternal age and the diffusion of fertility treatments. The major risks for twins were fetal and infant mortality, preterm delivery, small for gestational age, and cerebral palsy. The rate of preterm delivery (<37 weeks) was 44.3% in France in 2003, and the relative risk was 8.8 (95% CI: 7.8-10.0), when compared with single pregnancies. Maternal age and fertility treatments do not change very much the perinatal risk of twins. CONCLUSION Twin pregnancies are a high risk group which needs more intensive medical care than single pregnancies. The perinatal information system should be improved in France to monitor perinatal indicators according to the number of fetuses in a proper way.
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Affiliation(s)
- B Blondel
- INSERM U953, Unité de recherche épidémiologique sur la santé périnatale et la santé des femmes et des enfants, 94805 Villejuif cedex, France.
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Zhong Y, Li J, Ying Y, Wu H, Zhou C, Xu Y, Wang Q, Li J, Shen X. The efficacy of conversion from IUI to IVF-ET in infertility patients with hyper-response to ovulation induction: a retrospective study. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2012; 156:159-63. [PMID: 22837137 DOI: 10.5507/bp.2012.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The aim of the study was to determine the efficacy of in vitro fertilization and embryo transfer (IVF-ET) in patients with hyper-response to ovulation induction for intrauterine insemination (IUI). METHODS Patients with polycystic ovary syndrome (PCOS) who were initially treated with IUI in our centre between Jan 2007 and Oct 2010 were retrospectively analyzed. The ovarian hyper-stimulation syndrome (OHSS) found in 50 patients was then treated with IVF-ET following informed consent. RESULTS The fresh transfer had 42 cycles and a total of 87 embryos were transferred. Urine pregnancy tests were positive in 15 patients and fetal heart beat was detected in 12 patients by transvaginal ultrasound, from which 3 patients had two fetuses, 2 patients had three fetuses, and 7 patients had a single fetus. The overall clinical pregnancy rate was 28.5% (12/42) for the fresh embryo transfer. A total of 21 cycles of frozen embryo transfer with up to 55 embryos were conducted for patients who were not pregnant at the end of fresh embryo transfer cycles or who did not receive fresh embryo transfer in the first place. Urine pregnancy tests were positive in 10 patients and fetal heart beat was detected in 8 patients. The clinical pregnancy rate was 38.1% (8/21) for frozen embryo transfer. CONCLUSION We conclude that IVF-ET is an effective method for patients with hyper-response to ovulation induction in IUI.
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Affiliation(s)
- Yiping Zhong
- Reproductive Medicine Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China, 510080
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Biard JM, Bernard P, Thomas K, Hubinont C. Conservative management of triplet pregnancy after delivery of one foetus. ACTA ACUST UNITED AC 2012. [DOI: 10.1375/twin.3.2.71] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Talwar P, Sharma RK, Sandeep K, Sareen S, Duggal BS. Embryo reduction: our experience. Med J Armed Forces India 2011; 67:241-4. [PMID: 27365814 PMCID: PMC4920827 DOI: 10.1016/s0377-1237(11)60050-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2010] [Accepted: 03/31/2011] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The transvaginal ultrasound-guided embryo reduction technique is a feasible option for the prevention and management of the medical and obstetric risks associated with high-order multiple pregnancy resulting from assisted reproductive treatment. METHOD Multifoetal pregnancy reduction was carried out in 51 in vitro fertilisation pregnancies (IVF) and one intrauterine quintuplet pregnancy resulting from intrauterine insemination (IUI) using transvaginal approach under ultrasonographic guidance. RESULTS Of the 52 embryo reduction procedures, 48 (92%) were performed between the seventh and eighth weeks of gestation, three between eighth and ninth weeks and one in the 10th week of gestation. Forty-nine patients (94%) underwent reduction from triplets to twins, two from quadruplet to twins, and one from quintuplet to twin pregnancy. The average time required for the embryo reduction was 5.0 ± 0.5 minutes per sac in early gestation (6th-9th weeks), increasing to 8.5 minutes per sac for later procedures, due to technical difficulties brought about by increased embryo size and mobility. All embryo reduction procedures were successfully performed in a single session. CONCLUSION Transvaginal ultrasound guided embryo reduction technique performed between seventh and eighth-weeks of gestation is an effective and safe procedure for embryo reduction.
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Affiliation(s)
- Pankaj Talwar
- Classified Specialists (Obst and Gynae), ART Centre, AH (R & R), New Delhi – 10
| | - RK Sharma
- Consultant (Obst and Gynae), CH (SC), Pune
| | - K Sandeep
- Classified Specialists (Obst and Gynae), ART Centre, AH (R & R), New Delhi – 10
| | - Shashi Sareen
- RFWMO (Retd) (HQ Region), O/o DGAFMS, M Block, New Delhi
| | - BS Duggal
- Senior Advisor (Obst and Gynae), AH (R & R), New Delhi – 10
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Cararach V, Carmona F, Sentias J, Monleoan FJ, Andreu J, Deulofeu P, Gratacoas E. Frequency of Twin Pregnancies Following Renal Transplantation. Hypertens Pregnancy 2009. [DOI: 10.3109/10641959409084176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Corney G. Scientific Proceedings of the Multiple Birth Symposium, Queen Charlotte's Maternity Hospital, 3 October 1986. J OBSTET GYNAECOL 2009. [DOI: 10.3109/01443618709013675] [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]
Affiliation(s)
- G. Corney
- M. R. C. Human Biochemical Genetics Unit, The Galton Laboratory, University College London
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Lumme RH, Saarikoski SV. Multiple pregnancy with more than two fetuses. J OBSTET GYNAECOL 2009. [DOI: 10.3109/01443618709008774] [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]
Affiliation(s)
- R. H. Lumme
- Department of Obstetrics and Gynaecology, University of Tampere, Finland
| | - S. V. Saarikoski
- Department of Obstetrics and Gynaecology, University of Kuopio, Finland
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Dickey RP. Strategies to reduce multiple pregnancies due to ovulation stimulation. Fertil Steril 2008; 91:1-17. [PMID: 18973894 DOI: 10.1016/j.fertnstert.2008.08.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2008] [Accepted: 08/05/2008] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To review factors associated with high-order multiple births (HOMB) due to ovulation induction (OI) and the efficacy of strategies to reduce their occurrence. DESIGN Retrospective analysis of published studies of OI with intrauterine insemination (IUI) where patient and cycle characteristics were fully documented. RESULT(S) High-order multiple pregnancies (HOMP) were positively related to use of high doses of gonadotropin, number of 7-10 mm preovulatory follicles, and E(2), and inversely related to age and number of treatment cycles. Strategies successful in reducing HOMP include: use of clomiphene (CC) before gonadotropins, minimal gonadotropin doses, cancellation for more than three follicles >10-15 mm, and aspiration of excess follicles. Depending on the strategy used, 5%-20% of cycles may be canceled but HOMP rates can be less than 2% and pregnancy rates can average 10%-20% per cycle. Pregnancy rates per patient need not be reduced if low doses are continued for 4-6 cycles. CONCLUSION(S) High-order multiple pregnancies due to OI can be reduced to 2% or less by less aggressive stimulation without reducing overall chances of pregnancy for most patients.
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Affiliation(s)
- Richard Palmer Dickey
- Department of Obstetrics and Gynecology, Louisiana State University School of Medicine, The Fertility Institute of New Orleans, New Orleans, Louisiana, USA.
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van Rumste M, Custers I, van der Veen F, van Wely M, Evers J, Mol B. The influence of the number of follicles on pregnancy rates in intrauterine insemination with ovarian stimulation: a meta-analysis. Hum Reprod Update 2008; 14:563-70. [DOI: 10.1093/humupd/dmn034] [Citation(s) in RCA: 132] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Treatment of Unexplained Infertility With Aromatase Inhibitors or Clomiphene Citrate. Obstet Gynecol Surv 2008; 63:472-9. [DOI: 10.1097/ogx.0b013e31817d4e8d] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Homburg R. Oral agents for ovulation induction--clomiphene citrate versus aromatase inhibitors. HUM FERTIL 2008; 11:17-22. [PMID: 18320435 DOI: 10.1080/14647270701689670] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The purpose of this review is to compare clomiphene citrate (CC) with aromatase inhibitors (AI) as the first-line therapy for WHO Group II (eu-oestrogenic) infertility. For the past 45 years CC has been the first-line therapy, as it is a simple, cheap treatment, almost devoid of side effects, and yields ovulation in 73%, pregnancy in 36% and a singleton live birth rate of 25%. The gap between ovulation and pregnancy rates has mainly been attributed to its anti-oestrogen effects on endometrium. AI block oestrogen production, not oestrogen receptors, and would therefore be expected to produce superior conception rates and less multiple pregnancies. AI have yet to undergo further large, robust clinical trials in order to fulfill this promise as a feasible alternative to CC in this role, but some preliminary trials have shown at least equality and some superiority.
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Affiliation(s)
- Roy Homburg
- Division of Reproductive Medicine, Department of Obstetrics & Gynaecology, Vrije Universiteit Medical Centre, Amsterdam, The Netherlands.
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Kaufmann R, Dunn R, Vaughn T, Hughes G, O'Brien F, Hemsey G, Thomson B, O'Dea LSL. Recombinant human luteinizing hormone, lutropin alfa, for the induction of follicular development and pregnancy in profoundly gonadotrophin-deficient women. Clin Endocrinol (Oxf) 2007; 67:563-9. [PMID: 17692110 DOI: 10.1111/j.1365-2265.2007.02925.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To provide evidence of efficacy and safety for use of lutropin alfa in inducing follicular development and pregnancy in hypogonadotrophic hypogonadal women with profound gonadotrophin deficiency. DESIGN An open-label, noncomparative extension of a randomized, double-blind, placebo-controlled study PATIENTS A total of 31 hypogonadotrophic hypogonadal women with profound gonadotrophin deficiency in 23 medical centres in four countries were studied. INTERVENTIONS Lutropin alfa 75 IU and follitropin alfa (75-225 IU), individually based on each patient's response as is consistent with usual medical practice. MEASUREMENTS Follicular development as defined by (i) at least one follicle >or= 17 mm; (ii) preovulatory serum oestradiol level >or= 109 pg/ml on the day of hCG administration; and (iii) midluteal phase P(4) level >or= 7.9 ng/ml. Pregnancy and over-response leading to cycle cancellation were considered treatment successes. Pregnancy rates were assessed. RESULTS In a total of 54 cycles, 27 of 31 (87.1%) profoundly gonadotrophin-deficient patients achieved follicular development within three cycles. Twenty of 27 patients (74.1%) who achieved follicular development and received hCG became pregnant; 16 (59.3%) continued to clinical pregnancy. One patient was hospitalized for severe ovarian hyperstimulation syndrome. Lutropin alfa was well tolerated. CONCLUSIONS Coadministration of lutropin alfa 75 IU and follitropin alfa is safe and effective in inducing follicular development and pregnancy in hypogonadotrophic hypogonadal women with profound gonadotrophin deficiency in a setting consistent with established medical practice.
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Affiliation(s)
- Robert Kaufmann
- South-eastern Fertility Centre, PA, Mt. Pleasant, South Carolina, USA
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Abstract
Polycystic ovary syndrome is a heterogeneous endocrine disorder that affects about one in 15 women worldwide. The major endocrine disruption is excessive androgen secretion or activity, and a large proportion of women also have abnormal insulin activity. Many body systems are affected in polycystic ovary syndrome, resulting in several health complications, including menstrual dysfunction, infertility, hirsutism, acne, obesity, and metabolic syndrome. Women with this disorder have an established increased risk of developing type 2 diabetes and a still debated increased risk of cardiovascular disease. The diagnostic traits of polycystic ovary syndrome are hyperandrogenism, chronic anovulation, and polycystic ovaries, after exclusion of other conditions that cause these same features. A conclusive definition of the disorder and the importance of the three diagnostic criteria relative to each other remain controversial. The cause of polycystic ovary syndrome is unknown, but studies suggest a strong genetic component that is affected by gestational environment, lifestyle factors, or both.
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Affiliation(s)
- Robert J Norman
- Research Centre for Reproductive Health, School of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, South Australia, Australia
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Verberg MFG, Macklon NS, Heijnen EMEW, Fauser BCJM. ART: iatrogenic multiple pregnancy? Best Pract Res Clin Obstet Gynaecol 2007; 21:129-43. [PMID: 17074535 DOI: 10.1016/j.bpobgyn.2006.09.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Assisted reproductive technologies (ART) are now widely accepted as effective treatment for most causes of infertility. With improving success rates, attention has turned to the problem of multiple pregnancies, which are associated with a poor perinatal outcome, maternal complications and significant financial consequences. The challenge is to reduce multigestational pregnancies while maintaining good treatment outcomes. Methods to prevent multiple pregnancy include restrictive use of ART in couples with a good chance of spontaneous pregnancy, cautious use of gonadotrophins, and increased use of natural-cycle intra-uterine insemination and elective single embryo transfer in in-vitro fertilization and intracytoplasmic sperm injection. The aim of this article is to review the contribution of fertility treatment to multiple pregnancies and strategies for reducing multiples in ART.
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Affiliation(s)
- M F G Verberg
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands.
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Chen HJ, Huang LW, Lin YH, Seow KM, Hsieh BC, Hwang JL, Tzeng CR. Midtrimester maternal serum inhibin A levels after multifetal pregnancy reduction. Prenat Diagn 2007; 27:431-4. [PMID: 17295349 DOI: 10.1002/pd.1702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To investigate the relationship between the maternal serum inhibin A concentrations and the number of fetuses. Further, the maternal serum inhibin A levels for twin pregnancies and multiple pregnancies reduced to twins in the second trimester were compared. METHODS Three groups of women with pregnancies following in vitro fertilization and embryo transfer were recruited for this study. Groups 1, 2 and 3 included 20 singleton pregnancies, 37 twin pregnancies, and 35 multifetal pregnancies, respectively. In group 3, multifetal reduction was performed during 10-12 weeks of gestation. Blood samples were obtained longitudinally at 10th, 12th, 15th and 18th week of gestation. RESULTS There was a significant association between the number of fetuses and maternal plasma inhibin A prior to multifetal reduction. The inhibin A levels were not significantly different between twin and multifetal reduced twin pregnancies at 15th and 18th weeks of gestation. CONCLUSION In multifetal reduction to twin pregnancies, the maternal serum levels of inhibin A decrease to the level of twin pregnancies during the second trimester. Therefore, inhibin A may be effectively used as a marker for Down syndrome screening in cases of twin pregnancy following multifetal reduction.
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Affiliation(s)
- Heng-Ju Chen
- Department of Obstetrics and Gynecology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
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Tulandi T, Martin J, Al-Fadhli R, Kabli N, Forman R, Hitkari J, Librach C, Greenblatt E, Casper RF. Congenital malformations among 911 newborns conceived after infertility treatment with letrozole or clomiphene citrate. Fertil Steril 2006; 85:1761-5. [PMID: 16650422 DOI: 10.1016/j.fertnstert.2006.03.014] [Citation(s) in RCA: 227] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2006] [Revised: 03/22/2006] [Accepted: 03/23/2006] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To evaluate the incidence of congenital malformations among offspring of mothers who conceived with clomiphene citrate (CC) or with letrozole treatment for infertility. DESIGN Retrospective study. SETTING 5 fertility centers in Canada. PATIENTS 911 newborns from women who conceived following CC or letrozole treatment. INTERVENTIONS Examination of medical files of both mother and newborn, and cross-checked with the parents by telephone calls. MAIN OUTCOME MEASURES Identified major and minor congenital malformations, birth weight, age of the mother, and type of treatment that led to the conception. RESULTS Overall, congenital malformations and chromosomal abnormalities were found in 14 of 514 newborns in the letrozole group (2.4%) and in 19 of 397 newborns in the CC group (4.8%). The major malformation rate in the letrozole group was 1.2% (6/514) and in the CC group was 3.0% (12/397). One newborn in the letrozole group was found to have a ventricular septal defect (0.2%) compared to 4 newborns in the CC group (1.0%). In addition, the rate of all congenital cardiac anomalies was significantly higher (P: 0.02) in the CC group (1.8%) compared to the letrozole group (0.2%). CONCLUSION There was no difference in the overall rates of major and minor congenital malformations among newborns from mothers who conceived after letrozole or CC treatments. However, it appears that congenital cardiac anomaly is less frequent in the letrozole group. The concern that letrozole use for ovulation induction could be teratogenic is unfounded based on our data.
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Affiliation(s)
- Togas Tulandi
- Department of Obstetrics and Gynecology, McGill University, Montreal, Quebec, Canada
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Abstract
UNLABELLED Over the past 20 years, the number and rate of multiple births have dramatically increased in the United States. The rise in multiple births is mainly attributable to the increased use of ovulation-inducing drugs and the newly developed assisted reproductive technologies such as in vitro fertilization. Multifetal gestation is associated with an increased risk of perinatal morbidity and mortality. Multiple births account for an increasing percentage of low-birth-weight infants, preterm births, and infant mortality. In this section, we address the management of the multifetal pregnancy, focusing on the maternal physiology, the diagnosis, the pregnancy outcomes, and the antenatal management of multiple gestation. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES After completion of this article, the reader should be able to describe the effects of the rising rate of multiple pregnancies on perinatal morbidity and mortality, to recall the complications of diagnosing and treating abnormalities of multiple pregnancies, and to list the many changes that occur in both the mother and the fetuses in multiple pregnancies.
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Affiliation(s)
- Allen Ayres
- Department of OB/GYN Naval Medical Center Portsmouth, MFM Division, Norfolk, Virginia 23511, USA.
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Abstract
The purpose of this review is to examine whether the time has come to replace clomiphene citrate (CC) as the first line therapy for WHO group II (eu-oestrogenic) infertility, the majority of which is associated with polycystic ovary syndrome. CC has been the first line therapy for these cases for the last 40 years. It is a simple, cheap treatment, almost devoid of side effects which yields a single live birth rate of approximately 25% of starters. Non-response to CC and the gap between ovulation and pregnancy rates have variously been attributed to its anti-estrogen effects, and high LH and androgen concentrations. Three possible contenders for the replacement of CC as first-line treatment are scrutinized: metformin, aromatase inhibitors and low-dose FSH. Each has their advantages and disadvantages, but none of them, while showing much potential promise, has been proven, as yet, to be a feasible replacement for CC in this role. For CC, it may not yet be the end of an era but it may be the beginning of the end.
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Affiliation(s)
- Roy Homburg
- Division of Reproductive Medicine, Department of Obstetrics and Gynaecology, Vrije Universiteit Medical Centre, De Boelelaan 1117, PO Box 7057, 1007 MB Amsterdam, The Netherlands.
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Lambalk C, Huirne J, Macklon N, Fauser B, Homburg R. Ovulation induction with clomiphene or gonadotropins. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/j.ics.2005.01.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Dickey RP, Taylor SN, Lu PY, Sartor BM, Rye PH, Pyrzak R. Risk factors for high-order multiple pregnancy and multiple birth after controlled ovarian hyperstimulation: Results of 4,062 intrauterine insemination cycles. Fertil Steril 2005; 83:671-83. [PMID: 15749497 DOI: 10.1016/j.fertnstert.2004.10.030] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2004] [Revised: 10/28/2004] [Accepted: 10/28/2004] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine factors responsible for high-order multiple pregnancy (HOMP) and high-order multiple births when multiple cycles of controlled ovarian hyperstimulation-IUI (COH-IUI) are performed. DESIGN Retrospective analysis. SETTING Private infertility clinic. PATIENT(S) Women (n = 2,272) who underwent 4,067 consecutive COH-IUI cycles. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) High-order multiple pregnancy rate, pregnancy rate (PR), and birth rate (PR) per cycle. RESULT(S) High-order multiple pregnancy was related to number of follicles of diameter > or = 10 mm, age, and treatment cycle. For age <32 years, HOMP was 6% for three to six follicles and 20% for seven or more follicles. For ages 32 to 37 years, HOMP was 5% for three to six follicles and 12% for seven or more follicles. In the first COH-IUI cycle, HOMP was 8% for three to six follicles and 15% for seven or more follicles. In the second cycle, HOMP did not occur unless there were more than six follicles. No HOMP occurred after the second cycle. Pregnancy rate did not increase significantly when there were more than four follicles. Continuing COH-IUI past the third cycle resulted in additional pregnancies in patients with one to eight follicles. CONCLUSION(S) High-order multiple pregnancy can be predicted by age and number of follicles of diameter > or = 10 mm. Controlled ovarian hyperstimulation is not necessary to achieve satisfactory overall pregnancy rates if ovulation induction is continued past the third cycle in low responders.
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Affiliation(s)
- Richard P Dickey
- The Fertility Institute of New Orleans, New Orleans, Louisiana 70128, USA.
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Use of clomiphene citrate in women. Fertil Steril 2004; 82 Suppl 1:S90-6. [PMID: 15363701 DOI: 10.1016/j.fertnstert.2004.05.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2003] [Revised: 06/20/2003] [Accepted: 06/20/2003] [Indexed: 11/28/2022]
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Hashimoto LN, Lindsell CJ, Brewer DE, Eichel MM, Donovan EF. Contributions of infertility treatment to very-low-birth-weight multiple birth infants receiving neonatal intensive care. Am J Obstet Gynecol 2004; 190:401-6. [PMID: 14981381 DOI: 10.1016/j.ajog.2003.07.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study was undertaken to determine proportions of very-low-birth-weight (VLBW) multiple birth infants receiving neonatal intensive care whose mothers received various types of infertility treatment and to evaluate infertility treatment-associated morbidity and mortality. STUDY DESIGN Study infants were multiples with birth weight 401 to 1500 g cared for in Cincinnati neonatal intensive care units from January 1996 to December 2000. Data were obtained retrospectively from the National Institute for Child Health and Human Development Neonatal Research Network registry. Use of infertility treatment (in vitro fertilization, injection or oral ovulation, and intrauterine insemination) was determined by maternal interview or chart review. The generalized estimating equation approach to logistic regression was used. RESULTS The study included 382 infants of 212 mothers: 201=spontaneous conception (53%), 93=in vitro fertilization (24%), 55=injection (14%), 15=oral (4%), and 18=intrauterine insemination (5%). Neither gestational age nor birth weight differed between groups. More female (58%, P=.003) and white infants (95%, P<.001) resulted from infertility treatment-induced pregnancies than from spontaneous pregnancies. Advancing gestational age significantly decreased odds for all outcomes. CONCLUSION Of VLBW multiples receiving neonatal intensive care, 47% are associated with infertility treatment. Infertility treatment does not influence outcomes in VLBW multiples.
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Affiliation(s)
- Laura Nickles Hashimoto
- Divisions of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
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Dickey RP, Taylor SN, Lu PY, Sartor BM, Rye PH, Pyrzak R. Relationship of follicle numbers and estradiol levels to multiple implantation in 3,608 intrauterine insemination cycles. Fertil Steril 2001; 75:69-78. [PMID: 11163819 DOI: 10.1016/s0015-0282(00)01631-9] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the relationship of follicle numbers and estradiol (E(2)) levels to multiple implantations in human menopausal gonadotropin (hMG) and clomiphene citrate (CC) cycles. DESIGN Fifteen-year prospective study. SETTING Private infertility clinic. PATIENT(S) Women who underwent 3608 cycles of husband or donor intrauterine insemination (IUI). INTERVENTION(S) Ovulation induction (OI) with CC, hMG, or CC+hMG. MAIN OUTCOME MEASURE(S) Pregnancy and multiple implantations. RESULT(S) Triplet and higher-order implantations-but not twin implantations-were related to age, E(2) levels, and number of follicles > or = 12 mm and > or = 15 mm, but not number of follicles > or = 18 mm, in hMG and CC+hMG cycles. For patients less than 35 years old, three or more implantations tripled when six or more follicles were > or = 12 mm, in CC, hMG, and CC+hMG cycles, and when E(2) was > or = 1000 pg mL in hMG and CC+hMG cycles. For patients 35 or older, pregnancy rates in hMG and CC+hMG cycles doubled when six or more follicles were > or = 12 mm, or E(2) levels were >1000 pg mL, whereas 3 or more implantations were not significantly increased. CONCLUSIONS Withholding hCG or IUI in CC, hMG, and CC+hMG cycles when six or more follicles are > or = 12 mm may reduce triplet and higher-order implantations by 67% without significantly reducing pregnancy rates for patients under 35 years of age.
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Affiliation(s)
- R P Dickey
- The Fertility Institute of New Orleans, New Orleans, Louisiana 70128, USA
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Barad DH, Witt BR. Multiple pregnancies and assisted reproductive technologies. JOURNAL OF WOMEN'S HEALTH & GENDER-BASED MEDICINE 2000; 9:101-7. [PMID: 10746513 DOI: 10.1089/152460900318597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- D H Barad
- Montefiore's Fertility and Hormone Center at Dobbs Ferry, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
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Pasqualotto EB, Falcone T, Goldberg JM, Petrauskis C, Nelson DR, Agarwal A. Risk factors for multiple gestation in women undergoing intrauterine insemination with ovarian stimulation. Fertil Steril 1999; 72:613-8. [PMID: 10521097 DOI: 10.1016/s0015-0282(99)00316-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To identify whether sperm characteristics after washing and/or ovulation induction cycle characteristics can predict the occurrence of multiple conception in patients undergoing ovarian stimulation and IUI. DESIGN Retrospective study. SETTING A gynecology clinic and an andrology laboratory at a tertiary care facility. PATIENT(S) One hundred patients with single pregnancies and 22 patients with multiple pregnancies. INTERVENTION(S) Patients underwent ovarian stimulation and IUI with their partner's sperm. MAIN OUTCOME MEASURE(S) Relation of patient characteristics, ovarian stimulation, and sperm characteristics after washing to the occurrence of multiple pregnancy. RESULT(S) The mean serum E2 level on the day of hCG injection was significantly higher in the multiple conception group, but the number of follicles was not. The total sperm count, total motile sperm count, and sperm motility after washing did not differ between the groups. However, couples with multiple pregnancies had sperm with a significantly higher amplitude of lateral head movement than couples with single pregnancies. A peak E2 level of >583 pg/mL on the day of hCG injection and sperm with an ALH of >4 microm after washing predicted the occurrence of multiple pregnancy. CONCLUSION(S) Sperm with an amplitude of lateral head movement of >4 microm and a peak E2 level of >583 pg/mL are significant risk factors for multiple pregnancy in patients undergoing IUI.
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Rotmensch S, Celentano C, Shalev J, Vishne TH, Lipitz S, Ben-Rafael Z, Glezerman M. Midtrimester maternal serum screening after multifetal pregnancy reduction in pregnancies conceived by in vitro fertilization. J Assist Reprod Genet 1999; 16:8-12. [PMID: 9987687 PMCID: PMC3468214 DOI: 10.1023/a:1022585326896] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Data about the effect of multifetal pregnancy reduction on midtrimester maternal serum levels of alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), and unconjugated estriol (uE3) are scarce and contradictory. Differing gestational ages at fetal reduction, transvaginal versus transabdominal needle insertion, and injection of different feticidal agents compound the analysis of published data. METHODS We examined clinical and laboratory data about 27 high-order gestations that were reduced to twins in the first trimester. Fetal reductions were performed transabdominally at 11.41 +/- 1.15 weeks' gestation by fetal intrathoracic injection of KCl, and maternal blood sampling was performed at 16.48 +/- 1.05 weeks. "Pseudo-risks" for singleton pregnancies were calculated by correcting serum analyte levels for twins. RESULTS Twenty-four (88.9%) of 27 patients had maternal serum AFP levels above 2.0 MoM (mean, 4.60 +/- 3.48 MoM; range, 1.49-14.85 MoM), however, none of the newborns had structural anomalies. AFP serum levels did not correlate with the number of reduced fetuses or with adverse obstetric outcome. The mean hCG levels were 1.22 +/- 0.49 MoM (range, 0.14-2.47), and the mean uE3 levels were 1.15 +/- 0.31 MoM (range, 0.56-1.84). Based on maternal age alone, seven patients (25.9%) would have been offered amniocentesis for a term Down syndrome risk greater than 1:384, whereas combined risk calculations with hCG and uE3 levels resulted in 1 (3.7%) screen-positive case (P < 0.01).
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Affiliation(s)
- S Rotmensch
- Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon, Israel
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Abstract
Ovulation induction using clomiphene citrate, gonadotropins, and gonadotropin-releasing hormone is reviewed. The short- and long-term consequences of these therapies are discussed in detail.
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Affiliation(s)
- B J Vollenhoven
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
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Abstract
Ambulatory management of multiple gestation requires careful and continuing care by the obstetrician. The initial evaluation should include a comprehensive history, including use of fertility enhancing drugs and ART, family history, social history; a general physical examination, including a pelvic examination; laboratory evaluation, including complete blood cell count, dipstick urinalysis for protein and glucose, urine culture, blood type, Rh factor and irregular blood antibody determination, serology for rubella, syphilis, hepatitis B surface antigen and varicella (if there is no history). A Papanicolaou smear should be done at the time of the pelvic examination, as should evaluation for bacterial vaginosis. Ultrasound assessment of placentation should be done at 14 weeks' gestation, but vaginal or perineal ultrasound of cervical length should be done at the initial visit. Other testing procedures should include repeat ultrasound evaluation for fetal growth every 4 weeks in a dichorionic placentation and every 3 weeks if monochorionic placentation is present. Triple screen MSAFP at 16-18 weeks' gestation and blood sugar screening at 22-26 weeks should be performed. After the first trimester, the patient should schedule physician visits every 2 weeks or less. Routine medications should include one prenatal vitamin per day, additional folic acid supplementation of 1.0 mg per fetus, supplemental iron preparation, and additional calcium to equal 1500 mg/day. The use of low-dose aspirin to prevent preeclampsia in twin gestations has not been adequately studied. Continuing vigilance by the knowledgeable obstetrician should occur. Multiple gestations should not be cared for by non-physician providers or by family physicians. Referral to a maternal-fetal medicine unit is recommended.
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Affiliation(s)
- S A Gall
- Department of Obstetrics and Gynecology, University of Louisville, KY 40292, USA
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Child TJ, Barlow DH. Strategies to prevent multiple pregnancies in assisted conception programmes. BAILLIERE'S CLINICAL OBSTETRICS AND GYNAECOLOGY 1998; 12:131-46. [PMID: 9930294 DOI: 10.1016/s0950-3552(98)80044-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
All assisted conception techniques are associated with an increase in the multiple pregnancy rate. Iatrogenic multiple births are increasing as the use of these technologies expands. The cornerstone of safe ovulation induction is careful ultrasound monitoring, with cancellation of cycles if excessive ovulation is expected. In in vitro fertilization (IVF) cycles, the main determinant of multiple pregnancy risk is the number of embryos replaced. The current move in IVF clinics is to reduce the risk of multiple pregnancy by reducing the number of embryos transferred. We would suggest a maximum of two embryos transferred to women under, for example, 39 years of age. Women of 39 years or over have a reduced chance of embryo implantation; they should be allowed the transfer of up to three embryos (the UK legal maximum).
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Affiliation(s)
- T J Child
- John Radcliffe Hospital, Women's Centre, Oxford, UK
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De Geyter C, De Geyter M, Nieschlag E. Low multiple pregnancy rates and reduced frequency of cancellation after ovulation induction with gonadotropins, if eventual supernumerary follicles are aspirated to prevent polyovulation. J Assist Reprod Genet 1998; 15:111-6. [PMID: 9547686 PMCID: PMC3454980 DOI: 10.1023/a:1023000719569] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Our purpose was to demonstrate the feasibility of the routine aspiration of supernumerary follicles in infertile patients with imminent polyovulation after ovulation induction with gonadotropins and to examine its effect on the frequency of cycle cancellation and on the (multiple) pregnancy rate. METHODS The data on 796 treatment cycles, performed between 1989 and 1996 on 410 infertile couples, were analyzed retrospectively. From October 1992, whenever necessary, supernumerary ovarian follicles were selectively aspirated transvaginally under ultrasound guidance to prevent the ovulation of more than three follicles. Thereafter, intrauterine insemination was performed. RESULTS After the adoption of transvaginal ultrasound-guided aspiration of supernumerary follicles into the treatment protocol in October 1992, the number of canceled cycles (P < 0.0001) and the multiple pregnancy rate (P < 0.01) were significantly reduced compared to those previously. The overall pregnancy rate remained stable. No ovarian hyperstimulation syndrome requiring hospitalization was noted, and no complications resulting from the follicle aspiration were registered. CONCLUSIONS Transvaginal ultrasound-guided aspiration of supernumerary ovarian follicles increases both the efficacy and the safety of ovulation induction with gonadotropins. Because of the limited equipment required, this method represents an alternative for conversion of overstimulated cycles to more costly alternatives such as in vitro fertilization.
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Affiliation(s)
- C De Geyter
- Woman's Hospital of the University, Münster, Germany
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Newman RB. Obstetric management of high-order multiple pregnancies. BAILLIERE'S CLINICAL OBSTETRICS AND GYNAECOLOGY 1998; 12:109-29. [PMID: 9930293 DOI: 10.1016/s0950-3552(98)80043-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
High-order multiples are increasingly common as a result of assisted reproductive technologies and represent pregnancies at exceptional risk. This article discusses the antepartum management of high-order multiples, which has in general been highly individualized and poorly studied. Care for high-order multiples should include preterm birth prevention education, the frequent assessment of maternal symptoms and cervical status by a consistent provider, individualized modification of activity, attention to maternal nutrition, ultrasonography for the assessment of fetal anatomy and intra-uterine growth and anticipation of maternal complications. Interventions such as prophylactic cerclage, uterine activity monitoring, prophylactic tocolysis or hospitalization have not improved outcome when used routinely, and guidelines for selective use will be presented. Specialized care for high-order multiples should be directed at identifying congenital anomalies, maximizing fetal growth and preventing early preterm birth, the effect of which will be to improve perinatal outcome for these exceptional pregnancies.
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Affiliation(s)
- R B Newman
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston 29425-2233, USA
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Fasouliotis SJ, Schenker JG. Multifetal pregnancy reduction: a review of the world results for the period 1993-1996. Eur J Obstet Gynecol Reprod Biol 1997; 75:183-90. [PMID: 9447372 DOI: 10.1016/s0301-2115(97)00132-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The objective of this work was to evaluate the outcome of multifetal pregnancy reduction and to provide an analysis of the ethical dilemmas associated with its application. The study design was based on data on over 1400 completed pregnancies that underwent multifetal pregnancy reduction as reported in the world literature during 1993-1996. The results were: A total of 1453 completed cases of multifetal pregnancy reduction are presented. The total survival rate was estimated to be 87.7%, resulting in a total pregnancy loss rate of 12.3%. The lowest survival rate is found to be in higher-order pregnancies of five or more fetuses (75.2%), whereas pregnancy loss rate seems to be similar for quadruplets, triplets and twins that underwent reduction (11.3%, 8.3% and 13.6%, respectively). A 33.3% of the total pregnancy loss rate occurred within four weeks from the procedure, whereas 66.7% occurred after the four weeks but at 24 weeks of gestation or earlier. The mean gestational age at delivery was estimated to be 33 weeks for pregnancies reduced to triplets, 35.8 weeks for those reduced to twins and 36.9 weeks for singletons, with 5% delivering at less than 28 weeks and 9.6% at 29-32 weeks. We conclude that multifetal pregnancy reduction has been established as an efficient and safe way to improve outcome of multifetal gestations, especially those with four or more fetuses and likely of triplets. As the experience from the procedure increases, it seems that reduction of triplets to twins can be offered to patients with satisfactory results. The reduction to singletons has not yet been established and is being performed only when medical indications exist. Prenatal genetic diagnosis should become an integral part of counselling on multiple pregnancy. Physicians should take whenever possible measures designed to prevent high multiple birth pregnancies. We also note that although multifetal pregnancy reduction improves significantly the outcome of multiple pregnancies, several ethical dilemmas arising from its application are still under dispute.
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Affiliation(s)
- S J Fasouliotis
- Department of Obstetrics and Gynecology, Hadassah University Hospital, Jerusalem, Israel
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Senöz S, Ben-Chetrit A, Casper RF. An IVF fallacy: multiple pregnancy risk is lower for older women. J Assist Reprod Genet 1997; 14:192-8. [PMID: 9130066 PMCID: PMC3454699 DOI: 10.1007/bf02766109] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Multiple pregnancy is one of the most important and preventable complications of in vitro fertilization (IVF) and embryo transfer. The general clinical practice in many IVF clinics is to transfer four or five embryos to older women if available, since pregnancy rates are lower in women older than 35 years of age. However, it is not clear whether the risk for multiple pregnancy is also lower. OBJECTIVE Our objective was to investigate whether transferring a higher number of embryos actually improves pregnancy outcome in older women, without increasing the risk for multiple pregnancy and to investigate other factors that may affect the occurrence of multiple pregnancy. SETTING The setting was university-based IVF program at The Toronto Hospital. DESIGN The design was a retrospective case series. PATIENTS AND METHODS The outcome of 1116 IVF cycles between January 1992 and December 1993 was investigated according to different age groups. MAIN OUTCOME MEASURE The main outcome measure was multiple pregnancies. RESULTS Seventy multiple pregnancies resulted from a total of 242 pregnancies. Overall pregnancy and multiple pregnancy rates were inversely correlated with age. However, when the data were adjusted for the number of embryos transferred, this trend disappeared. The result of multiple regression analysis showed that the multiple pregnancy rate was higher without improving the pregnancy rate when the number of embryos transferred exceeded three, regardless of the age of the patients, especially when more embryos were available than the number of transferred ones. CONCLUSIONS The number of embryos transferred should be limited to a maximum of three regardless of the age of patients, to reduce the high frequency of multiple gestations in an IVF program.
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Affiliation(s)
- S Senöz
- Department of Obstetrics and Gynecology, Toronto Hospital, University of Toronto, Ontario, Canada
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Fauser BC, Van Heusden AM. Manipulation of human ovarian function: physiological concepts and clinical consequences. Endocr Rev 1997; 18:71-106. [PMID: 9034787 DOI: 10.1210/edrv.18.1.0290] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- B C Fauser
- Department of Obstetrics and Gynecology, Dijkzigt Academic Hospital, Rotterdam, The Netherlands
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De Geyter C, De Geyter M, Castro E, Bals-Pratsch M, Nieschlag E, Schneider HP. Experience with transvaginal ultrasound-guided aspiration of supernumerary follicles for the prevention of multiple pregnancies after ovulation induction and intrauterine insemination. Fertil Steril 1996; 65:1163-8. [PMID: 8641491 DOI: 10.1016/s0015-0282(16)58332-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To avoid multiple pregnancies caused by ovulation induction. SETTING Infertile couples treated in the Women's Hospital and the Institute of Reproductive Medicine of the University of Münster, Münster, Germany. DESIGN The outcome of ovulation induction in patients in whom supernumerary ovarian follicles were aspirated transvaginally was compared with the outcome in patients in whom this intervention was not necessary. In a second randomized prospective study, the efficacy of a low dosage of gonadotropins was compared with a higher dosage. PATIENTS Two hundred twenty-seven couples suffering from male infertility, unexplained infertility, incipient ovarian failure, and polycystic ovaries. INTERVENTIONS Aspirations were performed if more than three follicles were sized > 14 mm. MAIN OUTCOME MEASURE Number of (multiple) pregnancies. RESULTS During 232 ovulation inductions, 127 aspirations of supernumerary follicles were performed (54.7%). The pregnancy rate (PR) in these cycles was similar to cycles in which aspirations were unnecessary (24.4% versus 21.9%). The efficacy of 75 units of FSH administered daily during the recruitment phase of follicular development was equivalent to 150 units of FSH (PR: 32.4% versus 31.6%), but supernumerary follicles were fewer (26.5% versus 76.3%). Six twins, two triplets (multiple PR: 10.4%), and no ovarian hyperstimulation syndrome occurred. CONCLUSIONS Transvaginal aspiration of supernumerary follicles does not reduce the PR in ovulation induction. Supernumerary follicles can be avoided by low-dose administration of gonadotropins without compromising the PR.
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Svendsen TO, Jones D, Butler L, Muasher SJ. The incidence of multiple gestations after in vitro fertilization is dependent on the number of embryos transferred and maternal age. Fertil Steril 1996; 65:561-5. [PMID: 8774287 DOI: 10.1016/s0015-0282(16)58154-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine if the incidence of multiple gestations after IVF differs significantly depending on the number of embryos transferred and maternal age. DESIGN Retrospective analysis of IVF database. SETTING Tertiary care academic center. PATIENTS One thousand eight hundred sixty-seven patients undergoing IVF with up to four embryos transferred during 1986 through 1993. MAIN OUTCOME MEASURES The rate of singleton and multiple gestations > 20 weeks estimated gestational age (EGA). RESULTS The incidence of triplet gestations > 20 weeks EGA among patients < or = 34 years of age with three versus four embryos transferred was 0.3% (1/335) versus 2.4% (15/662), respectively. The incidence of twin gestations > 20 weeks EGA among patients < or = 34 years of age with two versus four embryos transferred was 1.3% (3/234) versus 7.4% (46/622), respectively. Also among patients < or = 34 years of age, the incidence of singleton gestations > 20 weeks EGA with two versus three embryos transferred was 12.8% (30/234) versus 15.8% (53/335); with two versus four embryos was 12.8% (30/234) versus 17.2% (107/622); and with three versus four embryos was 15.8% (53/335) versus 17.2% (107/622), respectively. CONCLUSIONS In women < or = 34 years of age undergoing IVF-ET, the transfer of four versus three and four versus two embryos significantly increased the incidence of triplet and twin gestations, respectively, without significantly improving the chance of singleton conception. This implies that a policy of transferring only three embryos should be considered in this age group (realizing that such a policy may merit modulation if pretransfer embryo selection is used.).
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Affiliation(s)
- T O Svendsen
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk 23507, USA
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Abstract
The incidence of multifetal pregnancies has increased dramatically since the advent of assisted reproductive technologies. Preterm delivery accounts for most of the mortality associated with multifetal pregnancies. Multifetal pregnancy reduction is a safe and effective procedure designed to decrease the adverse outcomes associated with very preterm deliveries. The increased incidence of multifetal pregnancies combined with reliable techniques for prenatal diagnosis of genetic and structural fetal anomalies have led to an increase in the diagnosis of abnormal fetal conditions in parents carrying multiple gestations. The development of the procedure of selective termination has provided prospective couples the option of selective termination of the abnormal fetus and continuation of the pregnancy.
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Affiliation(s)
- J Stone
- Department of Obstetrics and Gynecology, Mount Sinai Medical Center, New York, NY 10029, USA
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Kuwahara A, Matsuzaki T, Kaji H, Irahara M, Aono T. Induction of single ovulation by sequential follicle-stimulating hormone and pulsatile gonadotropin-releasing hormone treatment. Fertil Steril 1995; 64:267-72. [PMID: 7615101 DOI: 10.1016/s0015-0282(16)57721-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To induce single follicular ovulation by sequential treatment with FSH and pulsatile GnRH. DESIGN Prospective study. PATIENTS Eighteen hypogonadotropic anovulatory patients. INTERVENTIONS In sequential treatment, daily FSH injection was switched to pulsatile GnRH administration (20 micrograms/120 minutes SC) when the follicle diameter reached 11 mm. In conventional FSH treatment, daily FSH injection was continued. In both cycles, hCG was given when the diameter of the dominant follicle reached 18 mm. MAIN OUTCOME MEASURES Developed follicle numbers and serum FSH concentrations during treatment. RESULTS Single follicular development was achieved in 80.0% of cycles by sequential treatment but in no cycle by conventional FSH treatment. The number of developed follicles was 1.26 +/- 0.55 (mean +/- SD) on sequential treatment and 3.94 +/- 1.48 on conventional FSH treatment. Preovulatory FSH level was significantly lower on sequential treatment than on conventional FSH treatment (5.26 +/- 1.80 versus 11.55 +/- 3.43 mIU/mL [conversion factor to SI unit, 1.00]). CONCLUSION The sequential treatment achieved single follicular development without complications. The sequential FSH-pulsatile GnRH treatment may offer a better chance for development of a single dominant follicle and ovulation.
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Affiliation(s)
- A Kuwahara
- School of Medicine, Department of Obstetrics and Gynecology, University of Tokushima, Japan
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