Embryo transfer and luteal support in natural cycles

Morphokinetic Characteristics and Developmental Potential of In Vitro Cultured Embryos from Natural Cycles in Patients with Poor Ovarian Response

Background. Patients with poor ovarian response to ovarian hyperstimulation represent an interesting group for studying the impact of embryo cleavage irregularities on clinical outcome since all embryos, regardless of their quality, are usually transferred to the uterus. The aim of our study was to follow the morphokinetics of fertilized oocytes from natural cycles in poor responders. Methods. Zygotes from 53 cycles were cultured in vitro for 3 days. The morphokinetics of their development and transfer outcomes were retrospectively analyzed for the normally and irregularly cleaved embryos. Results. Of all embryos, 30.2% had single and 20.8% multiple cleavage irregularities with the following prevalence: developmental arrest 30.2%, direct cleavage to more than two cells 24.5%, chaotic cleavage 13.2%, and reverse cleavage 11.3%. These embryos had longer pronuclear phases, first cytokinesis, second embryo cell cycles, and less synchronized divisions. The transfer of normally developing embryos resulted in an implantation rate of 30.8% and a delivery rate of 23.1%, but irregularly cleaved embryos did not implant. Conclusions. The use of time-lapse microscopy in poor responder patients identified embryos with cleavage abnormalities that are related with no or extremely low implantation potential. Gained information about embryo quality is important for counselling patients about their expectations.

Effectiveness of indometacin to prevent ovulation in modified natural-cycle IVF: a randomized controlled trial

Modified natural-cycle IVF has a lower pregnancy rate per started cycle as compared with IVF with ovarian stimulation due to, for example, premature ovulation. Indometacin administered before ovulation prevents follicle rupture. Therefore, addition of indometacin may improve the effectiveness of modified natural-cycle IVF. This double-blind, randomized, placebo-controlled trial with indometacin or placebo in 120 women aged 27-36 years compared the number of patients without premature ovulation as compared with the number of patients with one or more ovulations in a maximum of six cycles. Indometacin had no significant influence on the probability of a premature ovulation in patients during the six cycles (OR 2.38, 95% CI 0.94-6.04). A subgroup analysis showed a significant influence of indometacin in decreasing the probability of a premature ovulation in cycles without LH surge at the day of human chorionic gonadotrophin administration (OR 8.29, 95% CI 1.63-42.3, P=0.009). Although this study could not detect a significantly lower ovulation rate in the indometacin group versus the placebo group, the data suggest that a subgroup of patients without LH surge prior to oocyte retrieval might benefit from indometacin in modified natural-cycle IVF.

Luteal support in reproduction: when, what and how?

PURPOSE OF REVIEW

Luteal phase support (LPS) is an integral part of the IVF cycles treated by gonadotropin-releasing hormone analogues. There is a worldwide controversy concerning the type of hormones used for LPS, its dose, duration, when to start and when to stop. This review will cover original as well as recent data on this topic.

RECENT FINDINGS

There is a consensus in the literature among IVF centers that LPS is necessary for IVF cycles. Human chorionic gonadotropin is less commonly used than progesterone for LPS because of ovarian hyperstimulation syndrome risk. Several studies suggested that intramuscular progesterone is superior to vaginal progesterone for LPS; however, the majority of centers use vaginal progesterone to avoid side effects of intramuscular injection. There is no difference in pregnancy rate whether LPS is started on day of human chorionic gonadotropin, oocyte retrieval or embryo transfer. There is a strong evidence that LPS should be stopped either on the day of pregnancy test or the first ultrasound (6-7 weeks pregnancy). There is no evidence that addition of estrogen will improve pregnancy rate.

SUMMARY

Progesterone is the preferred option for LPS. It should start within 2 days from triggering ovulation and should end on day of beta human chorionic gonadotropin or the day of the first ultrasound (6-7 weeks pregnancy).