Extended coasting duration exerts a negative impact on IVF cycle outcome due to premature luteinization

The effect of early coasting on blastocyst development and outcome following blastocyst transfer in IVF/ICSI programme

Objective

Coasting is a well-known strategy to decrease severity of Ovarian Hyperstimulation Syndrome (OHSS). The purpose of this study is to assess the effect of Coasting on blastocyst development and subsequent clinical outcome following exclusive blastocyst transfer.

Methods

We conducted an observational cohort study of patients having blastocyst transfer following IVF/ICSI treatment. Patients undergoing IVF/ICSI cycles were included in the study. Patients at risk of OHSS were coasted. Outcome following exclusive blastocyst transfer was compared between coasted and non-coasted groups. The main outcome measures were the rate of blastocyst development and live birth rates in coasted and non-coasted cycles. Within coasted cycles, outcome was further analysed based on coasting duration and serum estradiol (E₂) drop (difference between peak E₂ and E₂ on day of HCG).

Results

A total of 166 coasted cycles and 656 non-coasted cycles had blastocyst transfer. Blastocyst development (45.97% vs. 48.6%) and live birth rates (45.18% vs. 43.44%) were not significantly different between coasted and non-coasted cycles. The overall clinical pregnancy (54.21% vs. 49.08%) and implantation rates (43.95% vs. 39.54%) following blastocyst transfer in coasted cycles were not significantly different from those of non-coasted cycles.

Conclusion

Coasting duration up to 6 days and drop in serum E₂ levels did not compromise blastocyst development, implantation, clinical pregnancy or live birth rates. We conclude that coasting with subsequent blastocyst transfer can be used as an effective strategy in patients at risk of OHSS with no detrimental effects on blastocyst development or live birth outcome.

Is Coasting Valuable in All Patients with Any Cause of Infertility?

OBJECTIVES

This study aimed to assess the influence of coasting duration on the number and quality of oocytes and fertilization rate in male factor infertile women and those with polycystic ovary syndrome (PCOS).

METHODS

In this prospective observational follow-up study, 114 patients undergoing coasting (53 women with male factor infertility and 61 women with PCOS) were evaluated at the Royan Institute Research Center, Iran, between 2010 and 2012.

RESULTS

The results were analyzed according to the coasting periods of 1-4 days. In normal females, the number of oocytes retrieved was significantly reduced after the second day (p = 0.004). In addition, a statistically significant drop was observed in the number of metaphase II oocytes and fertilization rate after the third day (p = 0.006 and p = 0.006, respectively). No significant differences were observed in the number and quality of oocytes retrieved and fertilization rate with regard to coasting days in PCOS patients.

CONCLUSION

Coasting with duration of more than three days should be performed with caution in normal females who are at risk of developing ovarian hyperstimulation syndrome.

Premature Progesterone Elevation Does Not Affect Pregnancy Outcome in High-Responder Patients Undergoing Short-Interval Coasting in IVF Cycles

Background

We aimed to present the relationship between premature progesterone elevation (PPE) and clinical outcomes in high-responder patients who had a coasting period of <4 days in length due to their high risk of developing ovarian hyperstimulation syndrome (OHSS) and who were treated with a long-acting gonadotropin-releasing hormone agonist (GnRH-agonist) protocol in in vitro fertilization-embryo transfer (IVF-ET) cycles.

Material/Methods

This retrospective study was conducted at the University Hospital Assisted Reproductive Technology Center. The outcomes of 101 patients undergoing IVF- intracytoplasmic sperm injection (ICSI) cycles who showed a high response to COH (estradiol >4000 pg/ml and/or >20 follicles each ≥10 mm in diameter and at least 20% ≥15 mm) and who were coasted for <4 days were evaluated. Number of oocytes, 2 pronuclei (PN) embryos, implantation rate, and live birth rate were measured.

Results

The incidence of PPE was 32.6%. Compared with those without PPE, patients with PPE had a higher number of oocytes retrieved. Total mature and fertilized oocytes and the mean number of embryos transferred were not significantly different between groups. Live birth rates (41.9% vs. 38.7%) and implantation rates (26.5% vs. 23%) were also not significantly divergent in the PPE and non-PPE groups, respectively.

Conclusions

P concentrations ≥1.3 ng/ml on the day of human chorionic gonadotropin (hCG) administration, designated in this study as PPE, does not appear to be related to adverse effects in terms of clinical outcomes in high-responder patients undergoing coasting <4 days due to their high risk of developing OHSS treated with a long-acting GnRH-a protocol in IVF-embryo transfer cycles.

Microdose flare protocol with interrupted follicle stimulating hormone and added androgen for poor responders--an observational pilot study

OBJECTIVE

To investigate whether temporarily withholding FSH and adding androgen could improve follicular response during a microdose flare protocol in women with slow follicular growth or asynchronous follicular development.

DESIGN

Observational pilot study.

SETTING

University-affiliated private fertility center.

PATIENT(S)

Twenty-six women aged 34-47 years with poor response to stimulation or a previous cancelled IVF cycle and with slow or asynchronous follicular growth during a microdose flare cycle.

INTERVENTION(S)

For 13 women, after initiation of ovarian stimulation using the microdose flare protocol, gonadotropin administration was interrupted and transdermal testosterone gel was added for several days (4.4 ± 1.2 d) starting after cycle day 7 (mean cycle day 10 ± 2.6).

MAIN OUTCOME MEASURE(S)

FSH, E2, follicular growth, and total number of mature oocytes retrieved were determined for all of the patients. Cycle cancellation rate as well as pregnancy rate following embryo transfer were also documented when applicable.

RESULT(S)

FSH levels declined (25.2 ± 6.5 to 6.8 ± 3.2 IU/L), E2 levels increased (896 ± 687 to 2,163 ± 1,667 pmol/L), and follicular growth improved significantly during gonadotropin interruption and were tracked for 2 days during this time frame. The average number of oocytes retrieved was 5.3 ± 2.6, and the ratio of mature to total oocytes was 4:5. Four of the 13 women in the interruption group conceived following frozen embryo transfer, whereas none in the control group did.

CONCLUSION(S)

The androgen-interrupted FSH protocol may improve follicular response to gonadotropins in cycles that might otherwise be cancelled.

Ovarian hyperstimulation syndrome: pathophysiology, staging, prediction and prevention

OBJECTIVE

To identify, appraise and summarize the current evidence regarding the pathophysiology, staging, prediction and prevention of ovarian hyperstimulation syndrome (OHSS).

METHODS

Two comprehensive systematic reviews were carried out: one examined methods of predicting either high ovarian response or OHSS and the other examined interventions aimed at reducing the occurrence of OHSS. Additionally, we describe the related pathophysiology and staging criteria.

RESULTS

Seven studies examining methods of predicting OHSS and eight more examining methods of predicting high ovarian response to controlled ovarian stimulation were included. Current evidence shows that the best methods of predicting high response are antral follicle count and anti-Müllerian hormone levels, and that a high ovarian response (examined by the number of large follicles, estradiol concentration or the number of retrieved oocytes) is the best method of predicting the occurrence of OHSS. Ninety-seven randomized controlled trials examining the effect of several interventions for reducing the occurrence of OHSS were included. There was high-quality evidence that replacing human chorionic gonadotropin by gonadotropin-releasing hormone agonists or recombinant luteinizing hormone, and moderate-quality evidence that antagonist protocols, dopamine agonists and mild stimulation, reduce the occurrence of OHSS. The evidence for the effect of the other interventions was of low/very low quality. Additionally, we identified and described 12 different staging criteria.

CONCLUSIONS

There are useful predictive tools and several preventive interventions aimed at reducing the occurrence of OHSS. Acknowledging and understanding them are of crucial importance for planning the treatment of, and, ultimately, eliminating, OHSS while maintaining high pregnancy rates.

Serum progesterone concentration on day of HCG administration and IVF outcome

To determine the relationship between serum progesterone on the day of human chorionic gonadotrophin (HCG) and the pregnancy outcome of IVF-embryo transfer treatment, 251 infertile patients undergoing IVF-embryo transfer with gonadotrophin-releasing hormone agonist (GnRHa) and recombinant FSH (rFSH) were prospectively studied. Among them, 118 patients underwent 118 cycles of frozen embryo transfer (FET) treatment, one cycle per patient. All the cycles were grouped according to serum progesterone concentration on the day of HCG administration (<3.97 nmol/l or >/=3.97 nmol/l). The incidence of progesterone elevation was 36.7% (92/251), and in this group the pregnancy rate was significantly lower (25.97 versus 48.57%; P < 0.001). If the serum progesterone on the day of HCG was over 6.0 nmol/l, their pregnancy outcome was much poorer (13.79 versus 44.68%). However, the pregnancy rate was similar in FET cycles whether the serum progesterone was over 3.97 nmol/l (34.00 versus 36.76%) or 6.0 nmol/l (42.86 versus 34.02%). In conclusion, serum progesterone on the day of HCG may predict IVF pregnancy outcome. The higher serum oestradiol and progesterone concentrations may affect endometrial receptivity. For patients with an extremely high progesterone concentration on the day of HCG (such as over 6.0 nmol/l), transfer of frozen embryos in a natural cycle is suggested.

Unexpected pregnancy despite extremely decreased estradiol levels during ovarian stimulation

OBJECTIVE

To report two patients with ongoing pregnancies despite a dramatically sharp decrease in E(2) levels after coasting.

DESIGN

Case report.

SETTING

Reproductive endocrinology and assisted reproduction unit of university hospital.

PATIENT(S)

One 30-year-old and one 25-year-old woman, both with unexplained infertility, in whom E(2) levels increased up to 6345 and 14,275 pg/mL during ovarian hyperstimulation and decreased by 79.5% and 75.5%, respectively, after coasting.

INTERVENTION(S)

Two IVF treatments during which coasting was performed after high E(2) levels were observed. IVF cycles were carried out despite abrupt E(2) decrease.

MAIN OUTCOME MEASUREMENT(S)

Development of ovarian hyperstimulation syndrome (OHSS) or fertilization, cleavage, implantation, and pregnancy rates.

RESULT(S)

Two embryos (one grade A and one grade B) were transferred into the 30-year-old patient and three embryos (all grade A) were transferred into the 25-year-old patient. Neither woman developed OHSS. Two pregnancies on going at gestational weeks 20 and 14, respectively.

CONCLUSION(S)

Coasting is practiced to avoid severe complications of ovarian hyperstimulation during IVF cycles and is achieved by withholding gonadotropins. The aim of coasting is to lower E(2) levels to a safer range; however, there has been no consistency with respect to the time of coasting or the safety rates of E(2) decrease. We believe that high rates of E(2) decrease after coasting do not have deleterious effects on implantation.

Short coasting of 1 or 2 days by withholding both gonadotropins and gonadotropin-releasing hormone agonist prevents ovarian hyperstimulation syndrome without compromising the outcome

OBJECTIVE

To evaluate the effect of short coasting, by withdrawing both gonadotropins and gonadotropin-releasing hormone (GnRH) agonist, on the prevention of severe ovarian hyperstimulation syndrome (OHSS) without compromising pregnancy outcome.

DESIGN

Retrospective study.

SETTING

Large urban medical center.

PATIENT(S)

Forty-four women who had been coasted during controlled ovarian hyperstimulation (COH) for in vitro fertilization (IVF).

INTERVENTION(S)

When >or=20 follicles >15 mm with serum estradiol (E(2)) level of 4000 pg/mL were detected, both gonadotropins and GnRH agonist were withheld for 1 to 2 days.

MAIN OUTCOME MEASURE(S)

Changes of serum E(2) levels, number of oocytes retrieved, pregnancy rate.

RESULT(S)

The mean serum E(2) level fell from 7915 pg/mL at the onset of coasting to 3908 pg/mL on the day of human chorionic gonadotropin (hCG) administration. The mean number of oocytes retrieved and fertilization rate were 17.2% and 75.0%, respectively. Eighteen patients became pregnant (43.9%), and the implantation rate was 12.7%. Twenty-eight patients were coasted for 1 day, and 13 were coasted for 2 days. The mean decrease rate of serum E(2) level was 45.3% in 1-day coasting and 26.4% (first day) and 75.3% (second day) in 2-day coasting. The pregnancy outcome was similar between both groups. After coasting, three mild and two severe cases of OHSS occurred.

CONCLUSION(S)

Coasting for 1 or 2 days can be used successfully to prevent OHSS without compromising IVF cycle outcome.

Application of GnRH antagonist in combination with clomiphene citrate and hMG for patients with exaggerated ovarian response in previous IVF/ICSI cycles

PURPOSE

To investigate if the combination of clomiphene citrate, hMG, and cetrorelix (CC/hMG/cetrorelix protocol) can be applied to patients who had excessive response to GnRHa long protocol.

METHODS

Fifty patients who coasted and failed to conceive in their first cycles stimulated with GnRHa long protocol were stimulated with CC/hMG/cetrorelix protocol. The peak serum estradiol levels, the need of coasting and prolonged coasting (>/=4 days), and the incidences of OHSS were compared.

RESULTS

The peak estradiol level was significantly lower with CC/hMG/cetrorelix protocol compared to GnRHa long protocol. With CC/hMG/cetrorelix protocol, only four patients (8%) needed coasting and no one coasted >/=4 days. In contrast, in the first cycles, 11 patients (22%) needed coasting >/=4 days. The incidence of moderate OHSS was significantly lower with CC/hMG/cetrorelix protocol.

CONCLUSIONS

The CC/hMG/cetrorelix protocol is an acceptable alternative protocol for patients who had excessive response to GnRHa long protocol.

The optimal length of 'coasting protocol' in women at risk of ovarian hyperstimulation syndrome undergoing in vitro fertilization

Ovarian hyperstimulation syndrome (OHSS) is a serious and potentially life-threatening complication following ovarian stimulation for in vitro fertilization (IVF). Coasting is the practice whereby the gonadotrophins are withheld and the administration of human chorionic gonadotrophin (hCG) is delayed until serum oestradiol (E2) has decreased to what is considered to be a safe level, to prevent the onset of OHSS. This study aimed to assess the length of coasting on the reproductive outcome in women at risk of developing OHSS. Coasting was undertaken when the serum E2 concentrations were > or = 17000 pmol/L but < 21000 pmol/L. Daily E2 measurements were performed and hCG was administered when hormone levels decreased to < 17000 pmol/L. Eighty-one women who had their stimulation cycles coasted were grouped according to the number of coasting days. Severe OHSS occurred in one case, which represented 1.2% of patients who underwent coasting because of an increased risk of developing the syndrome. No difference was found between cycles coasted for 1 - 3 days and cycles coasted for > or = 4 days in terms of oocyte maturity, fertilization and embryo cleavage rates. Women in whom coasting lasted for > or = 4 days had significantly fewer oocytes retrieved (P < 0.05) and decreased implantation rate (P < 0.05) compared to those coasted for 1 - 3 days. Pregnancy rate/embryo transfer and live birth rate did not differ between groups. In conclusion, coasting appears to decrease the risk of OHSS without compromising the IVF cycle pregnancy outcome. Prolonged coasting is, however, associated with reduced implantation rates, perhaps due to the deleterious effects on the endometrium rather than the oocytes.

Effect of coasting on cycle outcome during in vitro fertilization/intracytoplasmic sperm injection cycles in hyper-responders

OBJECTIVE

To investigate the effect of coasting on IVF outcome in GnRH agonist cycles.

DESIGN

Retrospective analysis.

SETTING

Private IVF center.

PATIENT(S)

Infertile couples undergoing IVF/intracytoplasmic sperm injection (ICSI) treatment (normal responders [control], hyper-responders [coasting] groups).

INTERVENTION(S)

Coasting to reduce the risk of ovarian hyperstimulation syndrome (OHSS) among hyper-responders.

MAIN OUTCOME MEASURE(S)

Stimulation, embryology parameters, and pregnancy rate (PR).

RESULT(S)

The average length of coasting was 2.2 days. Age and baseline FSH were comparable to control cycles. There were more follicles and oocytes in the coasting group, but the number of fertilized oocytes and embryos transferred were similar. Implantation rate (22.4% vs. 13.9%) was higher in the control group but the PRs were comparable (45.1% vs. 38.5%). Within the coasting group, baseline, stimulation, and embryology parameters were comparable between successful and unsuccessful cycles. Pregnancy rates were comparable after 1, 2, and 3 or more days of coasting (36.3% vs. 38.4% vs. 40%). Pregnancy rates were also comparable (28.5% vs. 35.7% vs. 44.4%) when groups were compared based on change in E2 (<25%, 25%-50%, >50%).

CONCLUSION(S)

Coasting for 3 days can be used successfully in the management of the hyper-responding patients during IVF.

Coasting for the prevention of ovarian hyperstimulation syndrome: much ado about nothing?

OBJECTIVE

To review and critique the literature and our own experience regarding coasting as a strategy to prevent ovarian hyperstimulation syndrome (OHSS).

DESIGN

Identification of relevant clinical literature through PubMed and EMBASE databases, as well as the experience of our institution with this approach.

CONCLUSION(S)

Coasting is a rescue procedure that can be avoided by carefully adjusting the gonadotropin dosage. It is a good alternative that can be used to avoid cycle cancellation in extremely high responders to controlled ovarian hyperstimulation, who have a high risk of developing severe OHSS. Even if OHSS develops after coasting, both its incidence and severity will be diminished. Each case should be individually counseled to determine whether the patient should be coasted, and her hypothetical risks and benefits should be evaluated. Until the multifactorial etiopathogenesis of OHSS is completely understood, absolute prevention will not be possible, but coasting is definitely of great benefit.

[Apoptosis of the follicular cells: its implication in ovarian induction protocols]

Atresia, a degenerative process through which many follicles are removed from the grown pool of follicles involves apoptotic changes in the follicular cells. This review analyses the endocrine regulation of apoptotic cell death in ovarian follicle. FSH is the major survival factor for preovulatory follicle but follicle integrity, in vitro, was necessary to its action on granulosa cell. The role of LH is more ambivalent. FSH and LH exert their activity via activation of the cAMP signal. High levels of intracellular cAMP could enhance steroidogenesis and in the same time induce apoptosis in granulosa cells. Moreover, no correlation between steroidogenesis and apoptosis can be established. During ovarian stimulation in IVF protocol, the use of LH, of coasting and of GnRH agonists and antagonists could be deleterious in follicle survival.

Clinical pharmacology of gonadotrophin preparations

The practice of ovulation induction and superovulation for IVF has progressed in many ways since the first reports of pregnancies after IVF over 25 years ago. The pharmacology of gonadotrophins has advanced alongside other developments, leading to safer, easier and more effective treatments for anovular infertility and IVF ovulation induction. This review uses current concepts of the basic physiology of gonadotrophin actions during the natural ovarian cycle as a starting point from which to assess their uses in anovulation and assisted reproduction. The relative merits of urinary and recombinant gonadotrophins are discussed, along with their uses in combination with gonadotrophin-releasing hormone agonists and antagonists.