The use of gonadotropin-releasing hormone analogs for in vitro fertilization: comparison between the standard form and long-acting formulation of D-Trp-6-luteinizing hormone-releasing hormone

Depot versus daily administration of gonadotrophin-releasing hormone agonist protocols for pituitary down regulation in assisted reproduction cycles

BACKGROUND

Gonadotrophin-releasing hormone agonist (GnRHa) is commonly used to switch off (down regulate) the pituitary gland and thus suppress ovarian activity in women undergoing in vitro fertilisation (IVF). Other fertility drugs (gonadotrophins) are then used to stimulate ovulation in a controlled manner. Among the various types of pituitary down regulation protocols in use, the long protocol achieves the best clinical pregnancy rate. The long protocol requires GnRHa administration until suppression of ovarian activity occurs, within approximately 14 days. GnRHa can be used either as daily low-dose injections or through a single injection containing higher doses of the drug (depot). It is unclear which of these two forms of administration is best, and whether single depot administration may require higher doses of gonadotrophins.

OBJECTIVES

To compare the effectiveness and safety of a single depot dose of GHRHa versus daily GnRHa doses in women undergoing IVF.

SEARCH METHODS

We searched the following databases: Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched July 2012), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 7), MEDLINE (1966 to July 2012), EMBASE (1980 to July 2012) and LILACS (1982 to July 2012). We also screened the reference lists of articles.

SELECTION CRITERIA

We included RCTs comparing depot and daily administration of GnRHa for long protocols in IVF treatment cycles in couples with any cause of infertility, using various methods of ovarian stimulation. The primary review outcomes were live birth or ongoing pregnancy, clinical pregnancy and ovarian hyperstimulation syndrome (OHSS). Other outcomes included number of oocytes retrieved, miscarriage, multiple pregnancy, number of gonadotrophin (FSH) units used for ovarian stimulation, duration of gonadotrophin treatment, cost and patient convenience.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed study quality. For dichotomous outcomes, we calculated odds ratios (ORs) and 95% confidence intervals (CIs) per woman randomised. Where appropriate, we pooled studies.

MAIN RESULTS

Sixteen studies were eligible for inclusion (n = 1811 participants), 12 (n = 1366 participants) of which were suitable for meta-analysis. No significant heterogeneity was detected.There were no significant differences between depot GnRHa and daily GnRHa in live birth/ongoing pregnancy rates (OR 0.95, 95% CI 0.70 to 1.31, seven studies, 873 women), but substantial differences could not be ruled out. Thus for a woman with a 24% chance of achieving a live birth or ongoing pregnancy using daily GnRHa injections, the corresponding chance using GnRHa depot would be between 18% and 29%.There was no significant difference between the groups in clinical pregnancy rate (OR 0.96, 95% CI 0.75 to 1.23, 11 studies, 1259 women). For a woman with a 30% chance of achieving clinical pregnancy using daily GnRHa injections, the corresponding chance using GnRHa depot would be between 25% and 35%.There was no significant difference between the groups in the rate of severe OHSS (OR 0.84, 95% CI 0.29 to 2.42, five studies, 570 women), but substantial differences could not be ruled out. For a woman with a 3% chance of severe OHSS using daily GnRHa injections, the corresponding risk using GnRHa depot would be between 1% and 6%.Compared to women using daily GnRHa, those on depot administration required significantly more gonadotrophin units for ovarian stimulation (standardised mean difference (SMD) 0.26, 95% CI 0.08 to 0.43, 11 studies, 1143 women) and a significantly longer duration of gonadotrophin use (mean difference (MD) 0.65, 95% CI 0.46 to 0.84, 10 studies, 1033 women).Study quality was unclear due to poor reporting. Only four studies reported live births as an outcome and only five described adequate methods for concealment of allocation.

AUTHORS' CONCLUSIONS

We found no evidence of a significant difference between depot and daily GnRHa use for pituitary down regulation in IVF cycles using the long protocol, but substantial differences could not be ruled out. Since depot GnRHa requires more gonadotrophins and a longer duration of use, it may increase the overall costs of IVF treatment.

Depot versus daily administration of gonadotrophin releasing hormone agonist protocols for pituitary desensitization in assisted reproduction cycles

BACKGROUND

Gonadotrophin-releasing hormone agonist (GnRHa) has been widely used in cycles of in vitro fertilization (IVF). Among the various types of GnRHa ovarian stimulation protocols, the long protocol presents the best clinical pregnancy rates per cycle initiated (GnRHa administration until the suppression of ovarian activity is evident, within approximately 14 days). There are two types of GnRHa administration that can be used to lead to hypophysis desensitization in the IVF cycle in the long protocol: one consisting of daily GnRHa low doses, and another with the administration of analogues in higher long-acting doses (depot). There are controversies in the data as far as the number of ampoules to be used in the cycles with the depot GnRHa treatment, as well as regarding the number of follicles made available, the number of oocytes, fertilization, implantation and pregnancy rates.

OBJECTIVES

The objective of this study is to compare the use of a single long-acting depot dose to that of daily GnRHa doses in in vitro fertilization cycles.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group's specialised register of trials (searched 15 April 2004), Cochrane Central Register of Controlled Trials (Issue 2, 2004), MEDLINE (1984 to April 2004), EMBASE (1984 to June 2003), LILACS (1984 to April 2004) and reference lists of articles.

SELECTION CRITERIA

Types of studies: RCTs comparing depot and daily administration of GnRHa for long protocols in IVF treatment cycles.

TYPES OF PARTICIPANTS

Couples with any cause of infertility. Types of interventions: Ovarian stimulation with human follicle stimulating hormone (hFSH) and/or human menopausal gonadotropin (hMG) and/or recombinant follicle stimulating hormone (rFSH) in IVF treatment cycles. Types of outcome measures: Clinical pregnancy rates per woman, per oocyte retrieval procedure, per embryo transfer, number of oocytes retrieved, oocyte fertilization rates, ongoing/delivered pregnancy rates per cycle started, abortion rates, multiple pregnancy rates, number of ampoules of gonadotropin employed, ovarian hyperstimulation syndrome (OHSS) incidence rates, cost analysis and patient convenience.

DATA COLLECTION AND ANALYSIS

The reviewers evaluated allocation concealment, classified as adequate, uncertain or inadequate. Two reviewers extracted the data independently. All analyses were performed according to the intention-to-treat method.

MAIN RESULTS

Six studies, with a total of 552 women, were included and analysed. The studies do not indicate that there is statistically significant difference between the use of depot GnRHa or daily GnRHa in the primary outcome, clinical pregnancy rates per woman (OR 0.94, 95% CI 0.65 to 1.37). However, there was sufficient evidence that the use of depot GnRHa for pituitary desensitization in IVF cycles increased the number of gonadotrophins ampoules (WMD 3.30, 95% CI 1.27 to 5.34) and the duration of the ovarian stimulation (WMD 0.56, 95% CI 0.31 to 0.81), as compared with daily GnRHa.

AUTHORS' CONCLUSIONS

Although we recognise that the clinical pregnancy rates per woman are not the ideal primary outcome, we found no evidence of differences between the long protocol using depot or daily GnRHa for IVF cycles. However, the use of depot GnRHa is associated with increased requirements for gonadotrophins and a longer time required for ovarian stimulation. If these differences could be shown to translate into economic benefit, depot GnRHa should increase the overall costs of IVF treatment.

Depot versus daily administration of gonadotrophin releasing hormone agonist protocols for pituitary desensitization in assisted reproduction cycles

BACKGROUND

Gonadotrophin-releasing hormone agonist (GnRHa) has been widely used in cycles of in vitro fertilization (IVF). Among the various types of GnRHa ovarian stimulation protocols, the long protocol presents the best clinical pregnancy rates per cycle initiated (GnRHa administration until the suppression of ovarian activity is evident, within approximately 14 days). There are two types of GnRHa administration that can be used to lead to hypophysis desensitization in the IVF cycle in the long protocol: one consisting of daily GnRHa low doses, and another with the administration of analogues in higher long-acting doses (depot). There are controversies in the data as far as the number of ampoules to be used in the cycles with the depot GnRHa treatment, as well as regarding the number of follicles made available, the number of oocytes, fertilization, implantation and pregnancy rates.

OBJECTIVES

The objective of this study is to compare the use of a single long-acting depot dose to that of daily GnRHa doses in in vitro fertilization cycles.

SEARCH STRATEGY

Relevant RCTs were identified by electronic search of the following databases: MEDLINE, EMBASE, LILACS (Latin American and Caribbean Center on Health Sciences Information) and the Cochrane Controlled Trials Register.

SELECTION CRITERIA

Types of studies: The study analyses RCTs comparing depot and daily administration of GnRHa for long protocols in IVF treatment cycles.

TYPES OF PARTICIPANTS

Couples with any cause of infertility. Types of interventions: Ovarian stimulation with human follicle stimulating hormone (hFSH) and/or human menopausal gonadotropin (hMG) and/or recombinant follicle stimulating hormone (rFSH) in IVF treatment cycles. Types of outcome measures: Clinical pregnancy rates per woman, per oocyte retrieval procedure, per embryo transfer, number of oocytes retrieved, oocyte fertilization rates, ongoing/delivered pregnancy rates per cycle started, abortion rates, multiple pregnancy rates, number of ampoules of gonadotropin employed, ovarian hyperstimulation syndrome (OHSS) incidence rates, cost analysis and patient convenience.

DATA COLLECTION AND ANALYSIS

The reviewers evaluated allocation concealment, classified as adequate, uncertain or inadequate. Two reviewers extracted the data independently. All analyses were performed according to the intention-to-treat method.

MAIN RESULTS

Six studies, with a total of 552 women, were included and analysed. The studies do not indicate that there is statistically significant difference between the use of depot GnRHa or daily GnRHa in the primary outcome, clinical pregnancy rates per woman (OR 0.94, 95% CI 0.65 to 1.37). However, there was sufficient evidence that the use of depot GnRHa for pituitary desensitization in IVF cycles increased the number of gonadotrophins ampoules (WMD 3.30, 95% CI 1.27 to 5.34) and the duration of the ovarian stimulation (WMD 0.56, 95% CI 0.31 to 0.81), as compared with daily GnRHa.

REVIEWER'S CONCLUSIONS

Although we recognise that the clinical pregnancy rates per woman are not the ideal primary outcome, we found no evidence of differences between the long protocol using depot or daily GnRHa for IVF cycles. However, the use of depot GnRHa is associated with increased requirements for gonadotrophins and a longer time required for ovarian stimulation. If these differences could be shown to translate into economic benefit, depot GnRHa should increase the overall costs of IVF treatment.

Long-term down-regulation does not improve pregnancy rates in an in vitro fertilization program

OBJECTIVE

To investigate the effects of long-term down-regulation (4 months) used in combination with gonadotropin ovarian stimulation for IVF-ET.

DESIGN

Prospective randomized study.

SETTING

Assisted Reproduction Unit of the Hospital Clinic i Provincial in Barcelona, a tertiary care setting.

PATIENT(S)

Thirty pairs of IVF patients who were matched for age, indication for IVF, and number of attempts.

INTERVENTION(S)

Women were randomized to receive a standard long protocol of SC leuprolide acetate (n = 30, group L) or a monthly injection of leuprolide acetate depot for 4 months (n = 30, group D) before gonadotropin stimulation.

MAIN OUTCOME MEASURE(S)

Ovarian response and IVF outcome.

RESULT(S)

Days of ovarian stimulation, follicular recruitment and growth during gonadotropin treatment, and the endometrial thickness on the day of hCG administration were similar for the 2 groups of IVF patients. However, the serum concentration of E2 was significantly higher in group L even though group D received a higher total dose of gonadotropins. The number of follicles punctured, the number of oocytes retrieved, the number of oocytes fertilized, the number of embryos suitable for replacement and cryopreservation, the number of patients with ET, and implantation and clinical pregnancy rates were similar for groups L and D. However, the percentage of metaphase II oocytes was significantly higher in group L than in group D.

CONCLUSION(S)

Long-term down-regulation does not improve pregnancy rates in a general IVF program.

Effect of oocyte retrieval from a small leading follicle in fixed-schedule in vitro fertilization program

OBJECTIVE

To evaluate the propriety of oocyte retrieval (OR) form a small leading follicle during a fixed-schedule in vitro fertilization (IVF) program.

METHODS

OR was fixed only to take place on Wednesdays. Gonadotropin-releasing hormone agonist treatment was initiated on the first day of the cycle, human menopausal gonadotrophin was given for 7 days starting on the next Monday, and human chorionic gonadotrophin (hCG) was given on the Tuesday before the OR. Patients were divided into 2 groups according to the follicular size observed before the day of hCG administration: Group 1 (141 cycles), with follicles > 16 mm in mean diameter; and Group 2 (38 cycles) with follicles of 10 to 16 mm in mean diameter.

RESULTS

Fertilization rates and the incidence of mature oocytes were higher in Group 1 than in Group 2. However, the mean number of oocytes recovered and pregnancy rates were similar in the 2 groups.

CONCLUSION

It is worthwhile to retrieve the oocyte from a small leading follicle in a fixed-schedule IVF program.

Effects of a gonadotropin releasing hormone agonist on oocyte maturation, fertilization, and embryonal development of mice

PURPOSE

The effects of a GnRH agonist (GnRHa) on oocyte quality were investigated by assessing the influence of GnRHa on oocytes, and fertilized oocytes were examined in vivo and in vitro. Administration of gonadotropin in conjunction with GnRHa induced a significantly greater degree of germinal vesicle breakdown, significantly higher rates of in vitro fertilization, and significantly faster development of the oocytes than the pregnant mare serum gonadotropin alone

RESULTS

The hatching-success rate in the GnRHa treated hypophysectomized mice was higher than in control mice. The rate of in vitro fertilization was also higher in oocytes cultured in the presence of low loses of GnRHa and these effects were reversed by a GnRH antagonist.

CONCLUSION

Oocytes obtained following ovarian stimulation with GnRHa were of higher quality than control oocytes, and the efficacy of GnRHa may be due in part to its direct action on the ovary.

Comparison between depot and standard release triptoreline in in vitro fertilization: pituitary sensitivity, luteal function, pregnancy outcome, and perinatal results

OBJECTIVE

To compare the effects of depot and standard release form of triptoreline in superovulation induction in IVF programs.

DESIGN

One hundred ninety-six patients undergoing IVF were randomized between two treatment groups. Pituitary desensitization was obtained in group 1 (102 patients) with a single IM injection of 3.75 mg D-Trp-6-luteinizing hormone-releasing hormone (LH-RH) and, in group 2 (94 patients), with daily SC administration of 0.1 mg D-Trp-6-LH-RH. In a subgroup of 11 patients, a series of GnRH tests was performed to investigate pituitary desensitization and, in another subgroup of 12 patients, a study of luteal phase steroid profile was performed. In an additional 23 patients, a series of GnRH tests were performed to investigate pituitary desensitization during the late follicular and midluteal phases.

RESULTS

No differences were found in the time necessary to reach desensitization (11.3 +/- 1.03 versus 11.3 +/- 1.45 days; mean +/- SEM), whereas resumption of pituitary activity takes place in 7 days after the discontinuation of the daily form and in about 2 months after discontinuation of the depot form. No differences were found in the duration of stimulation, number of FSH ampules, E2 levels, and number of follicles (11.7 +/- 0.68, versus 12.2 +/- 0.68) on hCG administration day and the total oocytes collected (9.1 +/- 0.6 versus 9.2 +/- 0.64). Oocyte quality, percentage of fertilization and cleavage, pregnancy rate per transfer (28.7% versus 25.6%), and miscarriages (about 30%) were similar in the two protocols. No difference was found in hormonal levels during the luteal phase. In both groups there was a high incidence of multiple pregnancy.

CONCLUSION

Comparable results can be achieved with both long-acting and standard-release forms of GnRH analogs in patients undergoing assisted reproduction in terms of follicular stimulation and abortion rates despite differences in the duration of pituitary suppression.

The choice of a gonadotropin-releasing hormone analog influences outcome of in vitro fertilization treatment

OBJECTIVE

Our purpose was to determine if there is a difference in outcome associated with choice of gonadotropin-releasing hormone analog in in vitro fertilization treatment cycles.

STUDY DESIGN

A retrospective analysis of 510 consecutive in vitro fertilization cycles with patient-selected use of either nafarelin (Synarel) or leuprolide (Lupron) was performed.

RESULTS

Of 510 consecutive patient cycles, 284 patients (56%) chose nafarelin and 226 (44%) chose leuprolide. In the nafarelin group 64 cycles (34% of retrievals) resulted in deliveries. In the leuprolide group 37 (24%) resulted in delivery (p < 0.05). There were 260 patients in their first cycle of treatment, with 157 (60%) choosing nafarelin, resulting in 33 deliveries (34% per retrieval). Leuprolide, used in 103 (40%) of first cycles, resulted in 12 deliveries (20% per retrieval), (p = 0.052).

CONCLUSIONS

In a large population of unselected patients undergoing in vitro fertilization the choice of nafarelin was associated with a significantly better outcome in terms of successful pregnancies achieved.

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

OBJECTIVE

To determine if delaying initiation of exogenous gonadotropin administration after pituitary desensitization with gonadotropin-releasing hormone agonist (GnRH-a) is a realistic option to avoid scheduling clinical and laboratory work on weekends/holidays.

DESIGN, PATIENTS

A review of 57 in vitro fertilization (IVF) cycles in which, after pituitary desensitization with GnRH-a, initiation of gonadotropin administration were delayed in an attempt to avoid off-hour work. Thirty-eight IVF cohort cycles served as control.

SETTING

Tertiary medical center.

RESULTS

There were no statistically significant differences in ovarian response, dose of gonadotropin required, oocytes and embryos obtained, pregnancy rates, and abortion rates between groups. Eighty-three percent of the delayed cycles had clinical and laboratory work that fell within weekdays.

CONCLUSION

Delaying initiation of exogenous gonadotropin administration after pituitary desensitization had no detrimental effects on IVF outcomes. It may be used to avoid scheduling work on weekends/holidays.

The relative success of gonadotropin-releasing hormone analogue, clomiphene citrate, and gonadotropin in 1,099 cycles of in vitro fertilization

OBJECTIVES

To evaluate the effectiveness of and analyze the factors influencing the outcome of three ovarian stimulation protocols used during in vitro fertilization (IVF) in a large population.

DESIGN

Retrospective file review.

SETTING

In vitro fertilization program in one center during the years 1985 to 1990. PATIENTS AND PROTOCOLS: Three hundred forty-one patients received clomiphene citrate (CC) and human menopausal gonadotropin (hMG), 365 received hMG alone, and 393 received gonadotropin-releasing hormone analogue (GnRH-a) for pituitary suppression followed by hMG stimulation.

MAIN OUTCOME MEASURE

Rates of cancellation, total pregnancies, and ongoing pregnancies, with breakdown by age of patients.

RESULTS

The cancellation rate because of early luteinization following GnRH-a/hMG was significantly reduced compared with the other two protocols: 3.6% versus 9.4% and 13.7% for CC/hMG and hMG, respectively. However, in women over 40 years of age, GnRH-a/hMG resulted in the highest rate of poor ovarian response. Significantly more oocytes were retrieved, fertilized, and cleaved after the use of GnRH-a/hMG compared with the other two protocols. Despite this, clinical pregnancy rate (PR) was the highest with CC/hMG compared with GnRH-a/hMG and hMG:31.4% versus 16.9% and 15.7%, respectively. Ongoing PRs were 20.5%, 9.7%, and 11.6%, respectively.

CONCLUSIONS

Although the use of GnRH-a for pituitary suppression before ovarian stimulation for IVF reduced the cancellation rate and increased the number of retrieved oocytes, it was not found to result in higher PRs than those achieved by stimulation with CC/hMG. This suggests that treatment by GnRH-a/hMG should be reserved mainly for the prevention of early luteinization.

A prospective randomized study of the optimum timing of human chorionic gonadotropin administration after pituitary desensitization in in vitro fertilization

OBJECTIVE

To determine if there is an optimum time for the administration of human chorionic gonadotropin (hCG) after pituitary desensitization with gonadotropin-releasing hormone agonists (GnRH-a) has been achieved before ovarian stimulation for in vitro fertilization (IVF).

DESIGN

Prospective randomized study.

PATIENTS

Two hundred forty-seven patients undergoing an IVF treatment cycle who were randomly divided into three groups.

INTERVENTIONS

All patients were administered subcutaneously buserelin acetate 500 micrograms/d from day 1 of the menstrual cycle. After pituitary desensitization had been achieved at least 14 days later, ovarian stimulation with human menopausal gonadotropin was commenced. Ovarian stimulation, cycle monitoring, oocyte recovery, and IVF and embryo transfer (ET) techniques were identical in all three groups. Patients in group 1 (n = 79) had hCG administered when the mean diameter of the largest follicle had reached 18 mm, at least two other follicles were greater than 14 mm, and serum estradiol (E2) levels were consistent with the number of follicles observed on ultrasound. Patients in groups 2 (n = 84) and 3 (n = 84) had hCG administered 1 day and 2 days, respectively, after the above criteria had been reached.

RESULTS

The mean day of hCG administration (P less than 0.01), maximum serum E2 concentration (P = 0.06), number of days of serum E2 rise (P = 0.03), and mean diameter of the largest follicle (P less than 0.0001) were significantly different. There were, however, no significant differences in the mean number of preovulatory and medium size follicles, number of oocytes recovered or embryos transferred. There were also no significant differences in the oocyte recovery, fertilization and cleavage rates, in the number of embryos frozen, or in the pregnancy rates per initiated cycle and per ET.

CONCLUSIONS

There is no significant advantage in the precise timing of hCG administration after pituitary desensitization with GnRH-a.

Programming in vitro fertilization for a 5- or 3-day week

OBJECTIVE

To schedule oocyte retrievals on either 5 or 3 days per week in in vitro fertilization (IVF) cycles.

DESIGN

Human chorionic gonadotropin (hCG) administration was delayed by at least 24 hours in patients undergoing superovulation to avoid egg collections on weekends (group 1). Encouraged by the results, a further prospective study in which oocyte retrievals were programmed for only 3 days a week was undertaken (group 2).

SETTING

Hammersmith Hospital, a tertiary referral unit.

PATIENTS

All patients undergoing IVF treatment were included.

MAIN OUTCOME MEASURES

To schedule oocyte retrievals on either 5 or 3 days per week.

RESULTS

Only 4.0% of egg collections (12/303) occurred on weekends compared with 12.6% (22/175) before delaying hCG. In group 2 (n = 215), only four egg collections (2.1%) had to be performed out of schedule. Delaying administration of hCG had no detrimental effects.

CONCLUSIONS

Delayed administration of hCG allows scheduling oocyte retrievals on either 5 or 3 days per week, leading to a substantial decrease in out-of-hours oocyte retrievals, reducing cycle costs, and facilitating efficiency. The method is applicable to assisted reproduction specialized units as well as district general hospitals that use gonadotropin-releasing hormone analogs in their superovulation regimens before IVF, gamete intrafallopian transfer, or intrauterine insemination.

Gonadotropin-releasing hormone agonists induce meiotic maturation and degeneration of oocytes in the in vitro perfused rabbit ovary

The present study was undertaken to assess the effects of gonadotropin-releasing hormone agonists (GnRH-a, buserelin and leuprolide acetate [LA]) on ovulation, oocyte maturation and degeneration, and steroid and prostaglandin production in the perfused rabbit ovary preparation. Ovulation did not occur in any of ovaries treated with buserelin or LA (10(2) to 10(4) ng/mL) in the absence of gonadotropin. Gonadotropin-releasing hormone agonists were associated with the resumption of meiosis in follicular oocytes in a dose-related manner. Furthermore, the addition of GnRH-a to the perfusate significantly increased the percentage of follicular oocytes that showed evidence of degeneration compared with contralateral untreated or human chorionic gonadotropin-treated controls. Prostaglandin E2 and prostaglandin F2 alpha production by the perfused rabbit ovaries were stimulated significantly by GnRH-a treatment. Exposure to GnRH-a failed to increase either progesterone or estradiol production by the perfused rabbit ovaries. These data demonstrate that GnRH-a act directly in the rabbit ovary to trigger meiotic maturation in oocytes within the follicles, concomitantly increasing oocyte degeneration.

Ovarian stimulation with gonadotropin-releasing hormone (GnRH) analogue improves the in vitro fertilization (IVF) pregnancy rate with both transvaginal and laparoscopic oocyte recovery

The relative impact of ovarian stimulation protocol and oocyte retrieval technique on success rates of in vitro fertilization program was studied in 200 patients. Sixty-three patients received gonadotropin-releasing hormone analogue (GnRHa) with human menopausal gonadotropin (hMG), and 137 received hMG only. The GnRHa + hMG protocol resulted in higher pregnancy rates than the hMG-only protocol (19.0 vs 9.5%, respectively; P less than 0.01) despite a lower cleavage rate. Oocyte retrieval was performed via laparoscopy in 100 patients and transvaginally in 100 patients. The number of oocytes recovered per cycle was 6.1 +/- 3.9 with laparoscopy and 7.0 +/- 3.1 transvaginally. Pregnancy rates were similar for both retrieval techniques (13 and 12%, respectively). A breakdown of these results showed that the advantage for the GnRHa + hMG protocol was not affected by the oocyte retrieval technique. A comparison of simultaneous blood and follicular fluid pH measured every 10 min during laparoscopy and transvaginal oocyte recovery revealed a constant decline in follicular fluid pH during laparoscopy, while no changes were observed during the vaginal procedure. We conclude that the improvement in in vitro fertilization results during the period of our study is due primarily to the introduction of GnRHa + hMG protocol rather than the method of oocyte retrieval.

The use of gonadotropin-releasing hormone agonist to regulate oocyte retrieval time

We investigated the use of a gonadotropin-releasing hormone agonist (GnRH-a) to assist in the synchronous entry of a fixed number of subjects into in vitro fertilization (IVF) and gamete intrafallopian tube transfer cycle. Using a protocol in which a GnRH-a was given in the follicular or luteal phase, the clinical pregnancy rate per procedure was 27%. We conclude that the use of a GnRH-a for synchronous cycles in IVF-embryo transfer is efficacious and results in acceptable pregnancy rates.

Follicle cysts after menstrual versus midluteal administration of gonadotropin-releasing hormone analog in in vitro fertilization

The incidence and behavior of follicle cysts after different timing of gonadotropin-releasing hormone analog (GnRH-a) administration was studied in 321 in vitro fertilization (IVF) cycles. Group M included 198 cycles in which GnRH-a was injected at menstruation. Of these, 171 (88.6%) were without cysts (group M1) and 27 (13.6%) with cysts (group M2). Group L comprised of 123 cycles in which GnRH-a was administered in the midluteal phase. Of them, 70 (56.9%) were without cystic finding (group L1), 19 (15.4%) with follicle cysts (group L2), and 34 cases (27.6%) with visible corpus luteum at the time of GnRH-a initiation (group L3). Both groups with follicle cysts demonstrated a higher luteinizing hormone peak and continuous elevated estradiol (E2) levels. In group M2, the E2 rise and the cysts persisted longer compared with group L2. Gonadotropin treatment was accordingly postponed until the cysts regressed spontaneously. Only two cases of group M2 required aspiration of the cysts. Follicle cyst formation is not related to the timing of GnRH-a administration and their occurrence did not have adverse effects on IVF outcome.