No detrimental effects in delaying initiation of gonadotropin administration after pituitary desensitization with gonadotropin-releasing hormone agonist

Are the cytokines TNF alpha and IL 1Beta early predictors of embryo implantation? Cross sectional study

The cross-talk between endometrium and embryo is not accessible to the researcher for obvious ethical reasons that let understand why implantation remains the black box of reproduction. We aimed to detect of the concentrations of IL-1β and TNF-α in endometrial secretion at the time of oocyte retrieval for early prediction of implantation. One hundred twenty women participated in the study during ICSI cycles. All women participating in the study included the following criteria; age; 22-36 years, BMI; less than 35 kg/m², a husband with oligo- or oligoasthenospermia. All women received controlled ovarian hyperstimulation and immediately after ovum pickup, an intrauterine flushing was done. Embryo transfer was done at the blastocyst stage five days after ovum pick up. Serum pregnancy tests were done for all women. The clinical pregnancy was defined as the appearance of the gestational sac and positive embryo cardiac activity was confirmed by TVS. The ongoing pregnancy was detected by abdominal ultrasound at 12 weeks. The participants were divided into two groups: the pregnant group and the non-pregnant group. Thirty-two and half percent of women got pregnant. There were non-significant differences between the two groups regarding the demographic, clinical and laboratory data except for the duration of infertility and concentrations of TNF-α and IL-1β. The concentrations of TNF-α and IL-1β were significantly higher in the pregnant group than the non-pregnant group.Therefore,The use of TNF-α and IL-1β to predict implantation in IVF is promising especially before embryo transfer. Clinical trial.gov registration NCT02854514.

Gonadotropin-releasing hormone analogs: Understanding advantages and limitations

Pituitary stimulation with pulsatile gonadotropin-releasing hormone (GnRH) analogs induces both follicle-stimulating hormone (FSH) and luteinizing hormone (LH). Pituitary gonadotropin secretions are blocked upon desensitization when a continuous GnRH stimulus is provided by means of an agonist or when the pituitary receptors are occupied with a competitive antagonist. GnRH antagonists were not available originally; therefore, prolonged daily injections of agonist with its desensitizing effect were used. Today, single- and multiple-dose injectable antagonists are also available to block the LH surge and thus to cause desensitization. This review provides an overview of the use of GnRH analogs which is potent therapeutic agents that are considerably useful in a variety of clinical indications from the past to the future with some limitations. These indications include management of endometriosis, uterine leiomyomas, hirsutism, dysfunctional uterine bleeding, premenstrual syndrome, assisted reproduction, and some hormone-dependent tumours, other than ovulation induction.

Effect of delayed initiation of gonadotropin in luteal long protocol on in vitro fertilization

OBJECTIVE

To evaluate whether delayed initiation of gonadotropin in luteal long protocol affected the outcome of in vitro fertilization (IVF).

STUDY DESIGN

Prospective randomized study at the reproductive centre of a university-based hospital. Eighty-five subfertile women undergoing IVF embryo transfer after a standardized gonadotropin-releasing hormone agonists (GnRHa) long protocol. The patients were randomized into group A (stimulated 3 weeks after GnRHa administration) and group B (stimulated 2 weeks after GnRHa administration), according to the time of gonadotropin initiation after GnRHa-mediated pituitary suppression. The main outcome measures were clinical pregnancy and live birth rates.

RESULTS

There were no significant differences in baseline characteristics such as age, body mass index and basal follicle-stimulating hormone (bFSH) between the two groups. In group B, the days of gonadotropin stimulation were significantly greater than that in group A (p < 0.05), while the total dose of gonadotropin in group A was comparable to that in group B. Serum luteinizing hormone was lower and follicle-stimulating hormone higher in group A than in group B (p < 0.05) on initiation day. There were no significant differences in hormone profile measurements between the two groups. Moreover, the clinical pregnancy rate, implantation rate, live birth rate, miscarriage rate and moderate ovarian hyperstimulation syndrome rate were not significantly different between the groups.

CONCLUSION

Delay of gonadotropin stimulation in a standard long protocol may increase clinical efficiency, without significantly changing clinical outcome.

Characterization of the reproductive effects of the anorexigenic VGF-derived peptide TLQP-21: in vivo and in vitro studies in male rats

VGF (nonacronymic) is a 68-kDa protein encoded by the homonymous gene, which is expressed abundantly at the hypothalamus and has been involved in the control of metabolism and body weight homeostasis. Different active peptide fragments are generated from VGF, including TLQP-21. Circumstantial evidence has suggested that VGF might also participate in the control of reproduction. Yet its mechanisms of action and the eventual role of specific VGF-derived peptides on the hypothalamic-pituitary-gonadal (HPG) axis remain unknown. Herein we report a series of studies on the reproductive effects of TLQP-21 as evaluated in male rats by a combination of in vivo and in vitro analyses. Central administration of TLQP-21 induced acute gonadotropin responses in pubertal and adult male rats, likely via stimulation of GnRH secretion, as documented by static incubations of hypothalamic tissue. In addition, in pubertal (but not adult) males, TLQP-21 stimulated LH secretion directly at the pituitary level. Repeated central administration of TLQP-21 to pubertal males subjected to chronic undernutrition was able to ameliorate the hypogonadotropic state induced by food deprivation. In contrast, chronic administration of TLQP-21 to fed males at puberty resulted in partial desensitization and puberty delay. Finally, in adult (but not pubertal) males, TLQP-21 enhanced hCG-stimulated testosterone secretion by testicular tissue in vitro. In summary, our data are the first to document a complex and multifaceted mode of action of TLQP-21 at different levels of the male HPG axis with predominant stimulatory effects, thus providing a tenable basis for the (direct) reproductive role of this VGF-derived peptide.

Drug delivery for in vitro fertilization: rationale, current strategies and challenges

In vitro fertilization has experienced phenomenal progress in the last thirty years and awaits the additional refinement and enhancement of medication delivery systems. Opportunity exists for the novel delivery of gonadotropins, progesterone and other adjuvants. This review highlights the rationale for various medications, present delivery methods and introduces the status of novel ideas and possibilities.

The science behind 25 years of ovarian stimulation for in vitro fertilization

To allow selection of embryos for transfer after in vitro fertilization, ovarian stimulation is usually carried out with exogenous gonadotropins. To compensate for changes induced by stimulation, GnRH analog cotreatment, oral contraceptive pretreatment, late follicular phase human chorionic gonadotropin, and luteal phase progesterone supplementation are usually added. These approaches render ovarian stimulation complex and costly. The stimulation of multiple follicular development disrupts the physiology of follicular development, with consequences for the oocyte, embryo, and endometrium. In recent years, recombinant gonadotropin preparations have become available, and novel stimulation protocols with less detrimental effects have been developed. In this article, the scientific background to current approaches to ovarian stimulation for in vitro fertilization is reviewed. After a brief discussion of the relevant aspect of ovarian physiology, the development, application, and consequences of ovarian stimulation strategies are reviewed in detail.

The influences of weather on patients with different ovarian responses in the treatment of assisted reproductive technology

PURPOSE

The purpose of this study was to evaluate the influences of tropical weather on patients with different ovarian responses in the treatment of assisted reproductive technology.

METHODS

Six-hundred fourty-seven women underwent their first treatment cycles were retrospectively analyzed. Patients received embryo transfer either 3 days or 5 days after oocyte retrieval, depending on the number and quality of embryos on day-2.

RESULTS

Significant correlations were demonstrated in the top quality embryo rates of day-3 and day-5 embryo transfers with temperature, humidity, and atmosphere pressure. The cumulative light hours negatively correlated with the implantation and pregnancy rates of day-3 embryo transfer (-.282 and -.282, respectively), while they positively correlated with those of day-5 embryo transfer (.225 and .224, respectively).

CONCLUSIONS

These results clearly suggest that weather may exert influences on the outcome of assisted reproductive technology. Patients with different ovarian responses or blastocyst culture and transfer may modify weather influences.

Expression of steroid receptors, their cofactors, and aromatase in human luteinized granulosa cells after controlled ovarian hyperstimulation

OBJECTIVE

To examine expression of androgen receptor (AR), AR cofactors, estrogen (E) receptor alpha, E receptor beta, progesterone receptor, steroid receptor coactivator-1, and aromatase in human luteinized granulosa cells collected during oocyte retrieval.

DESIGN

Prospective real-time reverse transcriptase-polymerase chain reaction study.

SETTING

Academic medical center.

PATIENT(S)

A total of 198 samples were brought into the study.

INTERVENTION(S)

Patients underwent the long protocol for assisted reproductive technology. Luteinized granulosa cells were collected transvaginally with ultrasound guidance. Quantitative reverse transcriptase-polymerase chain reaction was performed to quantify the mRNA expression of the investigated genes.

MAIN OUTCOME MEASURE(S)

The expression levels were determined as ratios between the studied genes and the reference gene beta-actin.

RESULT(S)

There is little AR expression in human luteinized granulosa cells immediately preceding ovulation under controlled ovarian hyperstimulation. All aspirated follicles, despite their antral size, displayed a similar mRNA expression of the investigated genes in the luteinized granulosa cells.

CONCLUSION(S)

This study supports the possibility of a transition of androgen action from being an enhancer of follicular differentiation (through the AR) to being a substrate of E synthesis (through aromatase) at the time of oocyte retrieval. The present study also demonstrates no effect of follicular size upon the status of steroid receptor mRNA expression in the luteinized granulosa cells when follicles were at least >1.5 mL.

Expression of insulin-like growth factor (IGF), IGF receptor, and IGF-binding protein messenger ribonucleic acids in luteinized granulosa cells from different size follicles after controlled ovarian hyperstimulation

PURPOSE

This study was conducted to determine the gene expression of insulin-like growth factors (IGFs), their receptors, and binding proteins (IGFBPs) in human luteinized granulosa cells collected during ovum retrieval.

METHODS

cDNA probes were used to analyze the gene expression of IGF-I, IGF-II, IGF type 1 receptor (IGFR-1), IGF type 2 receptor (IGFR-2), and IGFBP-1 to -6 in luteinized granulosa cells.

RESULTS

The levels of IGFBP-5 transcripts of the luteinized granulosa cells increased with increasing follicular fluid (FF) volume when follicles were grouped into 3 volume catagories of < or = 1.5 mL: > 1.5 mL but < or = 4.5 mL; and > 4.5 mL (0.28 +/- 0.64 vs. 0.41 +/- 0.76 vs. 0.46 +/- 0.92, p = 0.037).

CONCLUSIONS

The increased levels of IGFBP-5 transcripts in luteinized granulosa cells found with increased follicular fluid volume after COH may favor a shift toward diminished action of IGFs in larger follicles immediately prior to ovulation.

Determination of the efficiency of controlled ovarian hyperstimulation in the gonadotropin-releasing hormone agonist-suppression cycle using the initial follicle count during gonadotropin stimulation

PURPOSE

Our purpose was to evaluate the relationship between the initial follicle count during gonadotropin stimulation after gonadotropin-releasing hormone (GnRH) agonist suppression and the efficiency of controlled ovarian hyperstimulation (COH) in patients receiving treatment with assisted reproductive technologies (ARTs).

METHODS

A total of 338 COH procedures in 291 couples was performed with cycles that reached the stage of oocyte retrieval. The ovarian antral follicle number was measured using transvaginal ultrasonography at the folliculometry during gonadotropin stimulation by GnRH agonist suppression in patients undergoing ARTs. Controlled ovarian hyperstimulation was accomplished using GnRH agonist down-regulation combined with FSH and menotropin stimulation. The characteristics of oocytes after retrieval and embryos after in vitro culture and the pregnancy rates were assessed.

RESULTS

The procedures performed included 195 ET cycles, 129 TET cycles, and 14 incomplete cycles. The treatment cycles were divided into four categories according to the antral follicle number (i.e., < or = 5, 6-10, 11-15, and > or = 16) at the first folliculometry to evaluate the influence of various factors. The antral follicle count correlated significantly with the patient age, dosage of gonadotropins, serum estradiol concentration, number of antral follicles (> or = 13 mm) while receiving hCG injections, number of oocytes retrieved, and, later, number of embryos transferred. There was a trend toward an increasing number of pregnancies per cycle as the number of antral follicles increased (14.7, 26.5, 44, and 45%, respectively).

CONCLUSIONS

We were able to predict the efficiency of COH and outcome of ARTs based on the follicle count during the first folliculometry during gonadotropin stimulation after GnRH agonist suppression. The results of the folliculometry significantly predicted the ovarian response to COH and the outcome of ARTs in the current treatment cycle.

The significance of delayed suppression using buserelin acetate and recombinant follicle-stimulating hormone in a long protocol in vitro fertilization program

OBJECTIVE

To determine whether the time taken to achieve ovarian suppression has an impact on ovarian responsiveness and the outcome of IVF-ET.

DESIGN

Retrospective analysis.

SETTING

An assisted reproduction unit at a university center.

PATIENT(S)

Patients undergoing a long protocol of IVF-ET that included buserelin acetate therapy initiated on day 2 of the cycle and recombinant FSH.

INTERVENTION(S)

Patients were divided into two groups according to the duration of buserelin acetate therapy required to achieve pituitary and ovarian suppression (group 1 = 2 weeks, n = 172; group 2 = > or =3 weeks, n = 337).

MAIN OUTCOME MEASURE(S)

Number of recombinant FSH ampules administered, duration of ovarian stimulation (days), ovarian response, and IVF outcome.

RESULT(S)

The patients in group 2 had lower mean E2 levels after 5 days and 9 days of stimulation than the patients in group 1. The number of recombinant FSH ampules administered and the number of days of stimulation required were higher in group 2 than in group 1. These differences were prominent in the subgroups of older patients (> or =36 years) and patients who had no evidence of polycystic ovaries on ultrasound examination. The number of oocytes retrieved and fertilized, the cancelation rate, and the pregnancy rate were similar in the two groups.

CONCLUSION(S)

Prolonged administration of a GnRH agonist to achieve suppression leads to a reduced ovarian response, particularly in women > or =36 years of age, but does not affect the success rate of IVF-ET.

Relationship of the human cumulus-free oocyte maturational profile with in vitro outcome parameters after intracytoplasmic sperm injection

PURPOSE

We investigated whether the human oocyte maturational profile at the removal of cumulus/corona cells affects the fertilization rate and subsequent embryo quality after intracytoplasmic sperm injection.

METHODS

A total of 1011 oocytes from 150 cycles was included in this retrospective analysis. Cumulus-free oocytes that were in prophase or metaphase I of meiosis at the removal of cumulus/corona cells were incubated in vitro until they reached metaphase II (in vitro-matured oocytes) and were then immediately injected with a single spermatozoa. Oocytes that were in metaphase II at the removal of cumulus/corona cells (MII oocytes) received sperm injection after 3-4 hr of preinjection incubation.

RESULTS

The fertilization rate of the MII oocytes was significantly higher than that of in vitro-matured oocytes (81 vs 62%; P < 0.001). The cleavage rates were similar in the two groups (MII oocytes, 94%; in vitro-matured oocytes, 91%). However, MII oocytes had significantly higher percentages of good-quality embryos (grade 1-3 embryos, 87 vs 58%, P < 0.001) and embryos with high cumulative embryo scores (score 10-32 embryos, 62 vs 33%, P < 0.001). The mean cumulative embryo score of MII oocytes after fertilization was also higher than that of in vitro-matured oocytes (12.1 +/- 3.8 vs 8.8 +/- 3.4; P = 0.014).

CONCLUSIONS

MII oocytes that extruded the first polar body at the removal of cumulus/corona cells had better fertilization rates and embryo morphology than in vitro-matured oocytes that extruded the first polar body following the removal of cumulus/corona cells and in vitro culture.

The behavior of follicle cysts formed after long-acting gonadotropin-releasing hormone analog administration in patients with polycystic ovarian syndrome

This study was conducted to examine the effect of ovarian cysts that develop after administration of a gonadotropin-releasing hormone (GnRH) analog during an ovulation induction program for patients with polycystic ovarian syndrome. Twenty-eight women received Decapeptyl Continuous Release for 70 cycles starting on day 3 of the menstrual cycle, after exclusion of any ovarian pathology by transvaginal ultrasonography. Fifteen days later ultrasonography was again performed and serum estradiol estimated. Cystic structures > or = 20 mm in the ovaries were defined as follicle cysts. In three cycles follicle cysts developed and low estradiol levels were measured (Group 1). In another six cycles cysts developed after GnRH analog, and elevated estradiol levels were found (Group 2). In the latter, estradiol decreased 3 to 7 days later, with cyst regression in three cases. Ovulation induction with human menopausal gonadotropin (hMG) was initiated only if the estradiol level was < or = 20 pg/ml, otherwise induction was postponed until estradiol decreased, disregarding the presence of cysts. When 2 to 3 follicles were > or = 18 mm, and generally when estradiol levels were < 1500 pg/ml, human chorionic gonadotropin was administered. All the cycles were ovulatory and two women from Group 2 conceived. The development of follicle cysts with low serum estradiol levels after GnRH analog administration represents a benign condition and is not a contraindication for hMG stimulation. In cases with elevated estradiol levels, ovulation induction can be postponed until the estradiol has decreased. Our study revealed good ovulatory and pregnancy rates as a result.

In vitro fertilization programmed for weekday-only oocyte harvest: analysis of outcome based on actual retrieval day

OBJECTIVE

Our aim was to assess the effect of the day of ovum retrieval on outcome in an IVF program scheduled for weekday-only ovum retrievals.

DESIGN

This was a retrospective study of patients who underwent transvaginal ultrasound-guided ovum retrieval (TVUS-OR) in an IVF program from August 10, 1992, to April 30, 1993.

SETTING

A university-based tertiary referral hospital center was the setting.

PARTICIPANTS AND METHODS

All patients (n = 501) who underwent TVUS-OR were divided into three groups: (1) patients who underwent TVUS-OR on Monday; (2) patients who underwent retrieval on Tuesday, Wednesday, or Thursday; and (3) patients who underwent retrieval on Friday. All patients were induced by the same controlled ovarian hyperstimulation protocol, which consisted of a GnRH analogue "flare-up" followed by parenteral menotropins, after a scheduled oral contraceptive-induced menses. Patients and cycle characteristics in the three groups were compared and clinical outcome was evaluated.

RESULTS

The similarity of patients and cycle characteristics confirmed the uniformity of the three groups. No difference was found in any of the clinical outcomes. However, in the first half of the program, we revealed a trend in which patients at high risk for ovarian hyperstimulation syndrome, requiring freezing all embryos and not allowing transfer during the treatment cycle, occurred more commonly in women whose retrieval occurred on Monday. This trend disappeared in the second half of the analysis.

CONCLUSIONS

In an in vitro fertilization program in which ovum retrievals occurred only on weekdays, no significant difference in outcome was found in patients undergoing ovum retrieval on Monday or Friday versus midweek. In addition to significant savings by eliminating weekend retrievals, IVF outcome is not compromised.

Significance of an abnormal response during pituitary desensitization in an in vitro fertilization and embryo transfer program

PURPOSE

Our purpose was to evaluate the IVF-ET outcome in patients who did not achieve timely pituitary-ovarian suppression following "long"-protocol GnRH agonist (GnRH-a) administration.

METHODS

A retrospective analysis was done on 96 IVF treatment cycles characterized by a delayed response (DR) to long-protocol GnRH-a treatment. The study included those patients who either achieved ovarian suppression (E2 < or = 110 pM) despite an elevated LH level (group DR-A) or had pituitary desensitization (LH < or = 1.5 IU/L) without ovarian suppression (group DR-B) on day 12 of GnRH-a treatment but needed an extended course of GnRH-a treatment to achieve complete suppression. These patients had gonadotropin stimulation either from day 12, despite an elevated level of LH (subgroup DR-A1; n = 13) or elevated E2 levels (subgroup DR-B1; n = 9), or after achieving a complete hypogonadotropic-hypopgonadal state following an extended course of GnRH-a treatment [subgroups DR-A2 (n = 46) and DR-B2 (n = 28)]. The outcome was compared with that of 88 cycles of normal responders (group NR) who had pituitary-ovarian suppression by day 12 day GnRH-a administration.

RESULTS

Ovarian response and pregnancy rates in subgroups DR-A1 and DR-A2 were statistically not different and comparable to those in the NR group. In subgroups DR-B1 and DR-B2, E2 response and rates of oocyte retrieval and pregnancy were significantly lower than those in the other groups, but fertilization and cleavage rates were similar. The requirement of gonadotropin for ovarian stimulation was comparatively higher in subgroup DR-A2 and both DR-B subgroups.

CONCLUSIONS

There was no treatment cancellation in group NR and both DR-A subgroups, but 22% of the cycles in DR-B1 and 14% of the cycles in DR-B2 were canceled due to poor ovarian response. It therefore appears that during long-protocol pituitary desensitization, the post-GnRH-a level of serum E2, rather than LH, better predicts IVF-ET outcome.

Follicular fluid levels of insulin-like growth factor I, insulin-like growth factor binding protein I, and ovarian steroids collected during ovum pick-up

OBJECTIVE

To evaluate interrelationships between levels of insulin-like growth factor I (IGF-I), insulin-like growth factor binding protein (IGFBP-I), and ovarian steroids in late preovulatory follicular fluid (FF) after pituitary desensitization with GnRH agonist and controlled ovarian hyperstimulation.

DESIGN

Follicular fluid and matched serum were collected during the ovum pick-up. Insulin-like growth factor binding protein I, E2, P, and androstenedione (A) were measured by means of RIA, whereas T was measured by means of fluoroimmunoassay and IGF-I by means of immunoradiometric assay.

SETTING

University teaching hospital.

PARTICIPANTS

Fifty-nine patients underwent 62 ovum pick-ups for IVF.

MAIN OUTCOME MEASURES

Levels of IGF-I, IGFBP-I, E2, P4 (representative of follicular maturity), T, and A in FF and the volume of this fluid were determined. Levels of E2 to A (representative of aromatase activity) in FF were examined in relation to the volume of FF.

RESULTS

Levels of FF-IGF-I decreased with increasing volume of FF. This observation is unprecedented. In contrast, FF-P increased with increasing volume of FF. The reverse relationships with FF volume between FF-IGF-I and FF-P may not be causal because no correlation was found between concentrations of FF-IGF-I and FF-P. Our findings are consistent with and complementary to those in previous reports. The follicular fluid E2:A ratio, FF-E2, FF-A, FF-T, and FF-IGFBP-I were not found to be correlated with volume of FF.

CONCLUSION

Decreased levels of FF-IGF-I with unaltered levels of FF-IGFBP-I in larger follicles may favor a shift toward diminished action of IGF-I at the time of immediate preovulation. The physiological significance of this shift remains uncertain as it is not reflected in the levels of steroids in FF.