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Palomba S, Costanzi F, Nelson SM, Besharat A, Caserta D, Humaidan P. Beyond the Umbrella: A Systematic Review of the Interventions for the Prevention of and Reduction in the Incidence and Severity of Ovarian Hyperstimulation Syndrome in Patients Who Undergo In Vitro Fertilization Treatments. Int J Mol Sci 2023; 24:14185. [PMID: 37762488 PMCID: PMC10531768 DOI: 10.3390/ijms241814185] [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: 08/03/2023] [Revised: 09/09/2023] [Accepted: 09/13/2023] [Indexed: 09/29/2023] Open
Abstract
Ovarian hyperstimulation syndrome (OHSS) is the main severe complication of ovarian stimulation for in vitro fertilization (IVF) cycles. The aim of the current study was to identify the interventions for the prevention of and reduction in the incidence and severity of OHSS in patients who undergo IVF not included in systematic reviews with meta-analyses of randomized controlled trials (RCTs) and assess and grade their efficacy and evidence base. The best available evidence for each specific intervention was identified, analyzed in terms of safety/efficacy ratio and risk of bias, and graded using the Oxford Centre for Evidence-Based Medicine (CEBM) hierarchy of evidence. A total of 15 interventions to prevent OHSS were included in the final analysis. In the IVF population not at a high risk for OHSS, follitropin delta for ovarian stimulation may reduce the incidence of early OHSS and/or preventive interventions for early OHSS. In high-risk patients, inositol pretreatment, ovulation triggering with low doses of urinary hCG, and the luteal phase administration of a GnRH antagonist may reduce OHSS risk. In conclusion, even if not supported by systematic reviews with homogeneity of the RCTs, several treatments/strategies to reduce the incidence and severity of OHSS have been shown to be promising.
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Affiliation(s)
- Stefano Palomba
- Unit of Gynecology, Sant’Andrea Hospital, Department of Surgical and Medical Sciences and Translational Medicine, Sapienza University of Rome, 00189 Rome, Italy; (F.C.); (A.B.); (D.C.)
| | - Flavia Costanzi
- Unit of Gynecology, Sant’Andrea Hospital, Department of Surgical and Medical Sciences and Translational Medicine, Sapienza University of Rome, 00189 Rome, Italy; (F.C.); (A.B.); (D.C.)
| | - Scott M. Nelson
- School of Medicine, University of Glasgow, Glasgow G12 8QQ, UK;
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol BS1 3NY, UK
- The Fertility Partnership, Oxford OX4 2HW, UK
| | - Aris Besharat
- Unit of Gynecology, Sant’Andrea Hospital, Department of Surgical and Medical Sciences and Translational Medicine, Sapienza University of Rome, 00189 Rome, Italy; (F.C.); (A.B.); (D.C.)
| | - Donatella Caserta
- Unit of Gynecology, Sant’Andrea Hospital, Department of Surgical and Medical Sciences and Translational Medicine, Sapienza University of Rome, 00189 Rome, Italy; (F.C.); (A.B.); (D.C.)
| | - Peter Humaidan
- The Fertility Clinic, Skive Regional Hospital, Faculty of Health, Aarhus University, Aarhus C, 8000 Aarhus, Denmark;
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Hsu I, Lee LH, Hsu L, Chen SU, Hsu CC. Disordered hypothalamus-pituitary-ovary axis in heterotopic extraovarian sex cord-stromal proliferation: a case report of fallopian tube serous adenofibroma. BMC Womens Health 2023; 23:243. [PMID: 37161407 PMCID: PMC10170719 DOI: 10.1186/s12905-023-02407-y] [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: 03/20/2023] [Accepted: 05/03/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Fallopian tube serous adenofibromas are uncommon tumors of the female genital tract, only dozens of cases have ever been reported. Earlier study indicated that they might be derived from embryonic remnants of the Müllerian duct. Clinical presentation of these tumors is usually asymptomatic. Small cysts of 0.5-3 cm in diameter are mostly incidentally found at the fimbriae end, with coarse papillary excrescences lined by epithelial cells and connective tissue stroma without nuclear pleomorphism or mitosis. CASE PRESENTATION A 23-year-old woman with normal secondary sexual characters and 46, XX karyotype, presented to the gynecology clinic complaining of irregular menstrual cycles. Laboratory studies reported unique discrepancy of hormone levels; anti-Müllerian hormone (AMH): 6.05 ng/mL (The normal range of AMH is 1.70-5.63 ng/mL in women aged under 35 years old), follicle stimulating hormone (FSH): 31.9 mIU/mL (reference range: 3.85-8.78, follicular phase; 4.54-22.51, ovulatory phase; 1.79-5.12, luteal phase; 16.74-113.59, menopause), and luteinizing hormone (LH): 52.0 mIU/mL (reference range: 2.12-10.89, follicular phase; 19.18-103.03, ovulatory phase; 1.20-12.86, luteal phase; 10.87-58.64, menopause), mimicking gonadotropin-resistant ovary syndrome. The ultrasound reported a right adnexal cyst of 10.4 × 7.87 × 6.7 cm. Laparoscopic evaluation was performed; pathology revealed serous adenofibroma of the fallopian tube with ovarian stroma contents. Heterotopic extraovarian sex cord-stromal proliferations was most probable. The patient's hormone levels returned to the reproductive status two weeks after surgery; FSH: 7.9 mIU/mL, LH: 3.59 mIU/mL,and AMH: 4.32 ng/mL. The patient's menstrual cycles have resumed to normal for over two years after removal of the fallopian tube cyst. CONCLUSIONS This case of fallopian tube serous adenofibromas presented a discrepancy of serum AMH and FSH mimicking gonadotropin-resistant ovary syndrome. The clinical picture derived from heterotopic extraovarian sex cord-stromal proliferation indicated a disordered hypothalamus-pituitary-ovary axis.
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Affiliation(s)
- Isabel Hsu
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
| | | | - Leonard Hsu
- Douglass Hanly Moir Pathology, Sydney, NSW, Australia
| | - Shee-Uan Chen
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chao-Chin Hsu
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan.
- Department of Obstetrics and Gynecology, National Cheng Kung University Hospital, Tainan, Taiwan.
- Department of Obstetrics and Gynecology, Taipei Medical University Hospital, Taipei, Taiwan.
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Rahav Koren R, Miller N, Moran R, Decter D, Berkowitz A, Haikin Herzberger E, Wiser A. GnRH agonist-triggering ovulation in women with advanced age. Sci Rep 2022; 12:16401. [PMID: 36180515 PMCID: PMC9525572 DOI: 10.1038/s41598-022-20619-4] [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: 06/19/2022] [Accepted: 09/15/2022] [Indexed: 11/09/2022] Open
Abstract
This study evaluates the effect of GnRH agonist (GnRHa) trigger for ovulation induction among women with advanced maternal age (AMA). This is a retrospective study performed at a single assisted reproductive technology centre, 2012 to 2020. A total of 306 patients with 515 IVF cycles who were triggered with GnRHa for Ovum Pick Up (OPU), were divided into two groups according to maternal age: age ≥ 40 and age < 40. The groups were compared for demographics, stimulation parameters of IVF treatment and IVF treatment outcomes. The patients in the age < 40 group were approximately 10 years younger than the patients in the age ≥ 40 group (31 ± 5.4 vs. 41.5 ± 1.3 years, p < 0.001). The age ≥ 40 group had significantly higher mean E2/retrieved oocytes ratio, compared to the age < 40 group (310.3 ± 200.6 pg/ml vs. 239 ± 168.2 pg/ml, p = 0.003), and a lower mean MII/retrieved oocyte (35 ± 37.8 vs. 43.4 ± 35.9, p = 0.05, respectively). Multivariable logistic regression analysis for E2/retrieved oocytes demonstrated that age < 40 and total dose of gonadotropins were significant variables. In conclusion, GnRHa for ovulation triggering in high responder patients prior to OPU appears to be a good option for AMA. However, this population is characterized by different parameters of ovarian response that require further evaluation.
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Affiliation(s)
- Roni Rahav Koren
- IVF Unit, Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tchernichovsky St., 4428164, Kfar Saba, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel.
| | - Netanella Miller
- IVF Unit, Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tchernichovsky St., 4428164, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel
| | - Rimon Moran
- IVF Unit, Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tchernichovsky St., 4428164, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel
| | - Dean Decter
- IVF Unit, Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tchernichovsky St., 4428164, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel
| | - Arie Berkowitz
- IVF Unit, Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tchernichovsky St., 4428164, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel
| | - Einat Haikin Herzberger
- IVF Unit, Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tchernichovsky St., 4428164, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel
| | - Amir Wiser
- IVF Unit, Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tchernichovsky St., 4428164, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel
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Li L, Zhang J, Lu C, Wang B, Guo J, Zhang H, Cui S. MicroRNA-7a2 Contributes to Estrogen Synthesis and Is Modulated by FSH via the JNK Signaling Pathway in Ovarian Granulosa Cells. Int J Mol Sci 2022; 23:ijms23158565. [PMID: 35955699 PMCID: PMC9369042 DOI: 10.3390/ijms23158565] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 07/28/2022] [Accepted: 07/30/2022] [Indexed: 11/22/2022] Open
Abstract
MicroRNA-7a2 (miR-7a2) plays fundamental roles in the female reproductive axis, and estrogen is indispensable for maintaining ovary function. However, the interaction between miR-7a2 and ovarian function is unclear. The present study aimed to determine whether and how miR-7a2 functions in estrogen synthesis. Firstly, the results verified that miR-7a was highly expressed in ovarian granulosa cells. The knockout (KO) of miR-7a2 caused infertility and abnormal ovarian function in mice. Concomitantly, the Cyp19a1 expression and estrogen synthesis were significantly inhibited, which was validated in primary granulosa cells. The mice transplanted with miR-7a2 KO ovaries showed similar results; however, estrogen supplementation reversed infertility. In the in vitro experiment, follicle-stimulating hormone (FSH) significantly improved the expression of miR-7a and Cyp19a1 and the synthesis of estrogen. However, the miR-7a2 KO markedly reversed the function of FSH. Also, FSH upregulated miR-7a by activating the (c-Jun N-terminal kinase) JNK signaling pathway. In addition, Golgi apparatus protein 1 (Glg1) was shown to be the target gene of miR-7a2. These findings indicated that miR-7a2 is essential for ovarian functions with respect to estrogen synthesis through the targeted inhibition of the expression of Glg1 and then promoting Cyp19a1 expression; the physiological process was positively regulated by FSH via the JNK signaling pathway in granulosa cells.
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Affiliation(s)
- Liuhui Li
- College of Veterinary Medicine, Yangzhou University, Yangzhou 225009, China; (L.L.); (C.L.); (B.W.); (J.G.); (H.Z.)
| | - Jinglin Zhang
- Institute of Reproduction and Metabolism, Yangzhou University, Yangzhou 225009, China;
- Joint International Research Laboratory of Agriculture and Agri-Product Safety, The Ministry of Education of China, Yangzhou University, Yangzhou 225009, China
| | - Chenyang Lu
- College of Veterinary Medicine, Yangzhou University, Yangzhou 225009, China; (L.L.); (C.L.); (B.W.); (J.G.); (H.Z.)
| | - Bingjie Wang
- College of Veterinary Medicine, Yangzhou University, Yangzhou 225009, China; (L.L.); (C.L.); (B.W.); (J.G.); (H.Z.)
| | - Jiajia Guo
- College of Veterinary Medicine, Yangzhou University, Yangzhou 225009, China; (L.L.); (C.L.); (B.W.); (J.G.); (H.Z.)
| | - Haitong Zhang
- College of Veterinary Medicine, Yangzhou University, Yangzhou 225009, China; (L.L.); (C.L.); (B.W.); (J.G.); (H.Z.)
| | - Sheng Cui
- College of Veterinary Medicine, Yangzhou University, Yangzhou 225009, China; (L.L.); (C.L.); (B.W.); (J.G.); (H.Z.)
- Institute of Reproduction and Metabolism, Yangzhou University, Yangzhou 225009, China;
- Jiangsu Co-Innovation Center for Prevention and Control of Important Animal Infectious Diseases and Zoonoses, Yangzhou 225009, China
- Correspondence:
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Anaya Y, Cakmak H, Mata DA, Letourneau J, Zhang L, Lenhart N, Juarez-Hernandez F, Jalalian L, Cedars MI, Rosen M. Triggering with 1,500 IU of human chorionic gonadotropin plus follicle-stimulating hormone compared to a standard human chorionic gonadotropin trigger dose for oocyte competence in in vitro fertilization cycles: a randomized, double-blinded, controlled noninferiority trial. Fertil Steril 2022; 118:266-278. [PMID: 35705380 DOI: 10.1016/j.fertnstert.2022.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 04/29/2022] [Accepted: 05/03/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess if triggering with 1,500 IU of human chorionic gonadotropin (hCG) with 450 IU of follicle-stimulating hormone (FSH) induces noninferior oocyte competence to a standard dose of hCG trigger used in in vitro fertilization (IVF). The alternative trigger will be considered noninferior if it is at least 80% effective in promoting oocyte competence. DESIGN Randomized, double-blinded, controlled noninferiority trial. SETTING Academic infertility practice. PATIENTS Women aged 18-41 undergoing IVF with antral follicle count ≥8, body mass index ≤30 kg/m2, and no history of ≥2 IVF cycles canceled for poor response were enrolled. Participants with a serum estradiol >5,000 pg/mL on the day of trigger were excluded because of high risk of ovarian hyperstimulation syndrome. INTERVENTIONS Participants were randomized to receive an alternative trigger of 1,500 IU of hCG plus 450 IU of FSH or a standard trigger dose of hCG (5,000 or 10,000 IU) for final oocyte maturation. MAIN OUTCOME MEASURES The primary outcome was total competent proportion, defined as the probability of 2 pronuclei from an oocyte retrieved. The alternative trigger will be considered noninferior to the standard trigger if a 1-sided 95% confidence interval (CI) of the relative risk (RR) is not <0.8. Secondary outcomes included oocyte recovery and maturity, intracytoplasmic sperm injection fertilization, embryo quality, pregnancy rates, as well as serum and follicular hormones. Secondary outcomes were compared using a 2-sided superiority test. Outcomes were analyzed by intention-to-treat and per-protocol. RESULTS A total of 105 women undergoing IVF were randomized from May 2015 to June 2018. The probability of the primary outcome was 0.59 with the alternative trigger and 0.65 with the standard trigger, with a RR of 0.91 and a 1-sided 95% CI of 0.83. Noninferiority of the alternative trigger was demonstrated. Live birthrate from all fresh transfers in the alternative trigger group vs. standard trigger was 46.9 vs. 46.4% (RR, 1.01; 95% CI, 0.62-1.62), respectively. Live birthrate per randomized participant was 48.1% in the alternative trigger group vs. 62.7% with the standard trigger (RR, 0.73; 95% CI, 0.48-1.11). No participants had a failed retrieval. CONCLUSION Triggering with 1,500 IU of hCG plus 450 IU of FSH promoted noninferior oocyte competence compared to a standard hCG trigger dose. TRIAL REGISTRATION NCT02310919.
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Affiliation(s)
- Yanett Anaya
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California.
| | - Hakan Cakmak
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California
| | - Douglas A Mata
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joseph Letourneau
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California; Division of Reproductive Endocrinology and Infertility, Utah Center for Reproductive Medicine, University of Utah, Salt Lake City, Utah
| | - Li Zhang
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Nikolaus Lenhart
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California
| | - Flor Juarez-Hernandez
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California
| | - Liza Jalalian
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California
| | - Marcelle I Cedars
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California
| | - Mitchell Rosen
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California
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Poulsen LC, Warzecha AK, Bülow NS, Bungum L, Macklon NS, Yding Andersen C, Skouby SO. Effects of letrozole cotreatment on endocrinology and follicle development in women undergoing ovarian stimulation in an antagonist protocol. Hum Reprod 2022; 37:1557-1571. [PMID: 35652260 DOI: 10.1093/humrep/deac119] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 04/17/2022] [Indexed: 12/25/2022] Open
Abstract
STUDY QUESTION What are the downstream endocrine and paracrine consequences of letrozole (LZ) cotreatment during ovarian stimulation and is follicle growth and recruitment affected? SUMMARY ANSWER Letrozole cotreatment induces marked changes in both the follicular and luteal phase endocrinology causing potentiation of follicle diameter and an improved corpus luteum function without affecting the secondarily recruited follicle cohort. WHAT IS KNOWN ALREADY Letrozole is a third-generation aromatase inhibitor that is well-established as an effective ovulatory agent, while its possible benefits in standard in vitro fertilization protocols are less thoroughly investigated. STUDY DESIGN, SIZE, DURATION This study included a double-blinded, placebo-controlled, randomized study with LZ or placebo intervention during ovarian stimulation for IVF treatment, an observational preceding baseline natural cycle and a succeeding follow-up visit. Participants were enrolled between August 2016 and November 2018. Data from the randomized, stimulated cycle were part of a larger RCT, which was previously published. PARTICIPANTS/MATERIALS, SETTING, METHODS The study was conducted at a public fertility clinic at Herlev Hospital, Denmark, including 31 healthy, normo-responding women eligible for IVF treatment. They underwent a natural baseline cycle and were subsequently randomized to receive either LZ 5 mg (n = 16) or placebo (n = 15) daily during ovarian stimulation from cycle day (CD) 2-3 until induction of ovulation. Throughout both cycles, monitoring was performed every third day with transvaginal ultrasound for assessment of follicle count and diameter, and blood analyses for the determination of twelve endocrine and paracrine parameters. A follow-up assessment was performed at CD2-3 in the succeeding cycle. In the randomized part of the study, we determined differences in blood parameters, follicle recruitment, and follicle diameter. In the observational part of the study, we assessed follicle recruitment in between cycles and its correlation to endocrine parameters. MAIN RESULTS AND THE ROLE OF CHANCE Letrozole cotreatment significantly suppressed oestradiol (E2) concentrations in the follicular phase (area under the curve (AUC) -58% (95% CI [-70%; -43%], P < 0.001)) and luteal phase (AUC -39% [-63%; -1%], P = 0.046). This had a marked effect on the endocrine and paracrine output with increased follicular phase luteinizing hormone (AUC +37% [3%; 82%], P = 0.033), androstenedione (AUC +36% [6%; 74%], P = 0.016), testosterone (AUC +37% [7%; 73%], P = 0.013) and 17-OH-progesterone (AUC +114% [10%; 318%], P = 0.027). Furthermore, follicle-stimulating hormone (FSH) was increased at stimulation day 5 in the LZ group (P < 0.05). In the luteal phase, increased corpus luteum output was reflected by elevated progesterone (AUC +44% [1%; 104%], P = 0.043), inhibin A (AUC +52% [11%; 108%], P = 0.011), androstenedione (AUC +31% [9%; 58%], P = 0.006) and testosterone (AUC +29% [6%; 57%], P = 0.012) in the LZ group. The altered balance between oestrogens and androgens was reflected in a markedly reduced SHBG concentration in the LZ group throughout the luteal phase (AUC -35% [-52%; -11%], P = 0.009). Endocrine and paracrine parameters were similar between groups at the follow-up visit. Letrozole cotreatment significantly increased the mean number of follicles >16 mm at oocyte retrieval (7.2 vs 5.2, difference: 2.0, 95% CI [0.1; 3.8], P = 0.036), while the mean total number of follicles at oocyte retrieval was the same (23.7 vs 23.5, difference: 0.2 [-5.8; 6.1], P = 0.958), and the mean FSH consumption during the stimulated cycle was similar (1500 vs 1520 IU, difference -20 IU [-175; 136], P = 0.794). Between cycles, the mean antral follicle count at CD2-3 was unchanged (natural cycle 19.0, stimulated cycle 20.9, follow-up cycle 19.7, P = 0.692) and there was no effect of LZ cotreatment on the recruitment of the next follicle cohort (test for interaction, P = 0.821). LIMITATIONS, REASONS FOR CAUTION This study included a relatively small, selected group of healthy women with an expected normal ovarian function and reserve, and the effects of LZ may therefore be different in other patient groups. WIDER IMPLICATIONS OF THE FINDINGS We confirm some previous findings concerning increased follicle growth and increased endogenous FSH and androgen production, which support the rationale for further studies on the use of LZ cotreatment, for example, as a form of endogenous androgen priming sensitizing the follicle to FSH. Letrozole appears to improve the luteal phase with better stimulation of corpus luteum and progesterone secretion. STUDY FUNDING/COMPETING INTEREST(S) The authors declare no conflicts of interest relating to the present work. TRIAL REGISTRATION NUMBER NCT02939898.
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Affiliation(s)
- Liv C Poulsen
- Department of Gynaecology and Obstetrics, Endocrinological and Reproductive Unit, Copenhagen University Hospital, Herlev Hospital, Herlev, Denmark
| | - Agnieszka K Warzecha
- Department of Gynaecology and Obstetrics, Endocrinological and Reproductive Unit, Copenhagen University Hospital, Herlev Hospital, Herlev, Denmark
| | - Nathalie S Bülow
- Department of Gynaecology and Obstetrics, Endocrinological and Reproductive Unit, Copenhagen University Hospital, Herlev Hospital, Herlev, Denmark.,The Fertility Department, Copenhagen University Hospital, Copenhagen, Denmark
| | - Leif Bungum
- Fertility Clinic, Department of Gynaecology and Obstetrics, Zealand University Hospital, Køge, Denmark
| | - Nicholas S Macklon
- Fertility Clinic, Department of Gynaecology and Obstetrics, Zealand University Hospital, Køge, Denmark.,London Women's Clinic, London, UK
| | - Claus Yding Andersen
- Laboratory of Reproductive Biology, The Juliane Marie Centre for Women, Children and Reproduction, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sven O Skouby
- Department of Gynaecology and Obstetrics, Endocrinological and Reproductive Unit, Copenhagen University Hospital, Herlev Hospital, Herlev, Denmark
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7
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OUP accepted manuscript. Hum Reprod Update 2022; 28:717-732. [DOI: 10.1093/humupd/dmac012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/05/2022] [Indexed: 11/14/2022] Open
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8
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Sharma R, Meena I. To Compare the Effect of GnRH Agonist versus Human Chorionic Gonadotropin (HCG) Trigger on Clinical Pregnancy Rate in Intrauterine Insemination Cycle. J Hum Reprod Sci 2021; 14:267-272. [PMID: 34759616 PMCID: PMC8527070 DOI: 10.4103/jhrs.jhrs_100_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 03/26/2021] [Accepted: 06/09/2021] [Indexed: 11/05/2022] Open
Abstract
Context: Gonadotropin-releasing hormone (GnRH) agonist trigger mimics the natural surge more closely with both luteinizing hormone (LH) and follicle-stimulating hormone surge. The present study attempts to find whether this apparent physiological advantage translates into the better pregnancy rate. Aims: To compare the effect of GnRH agonist versus human chorionic gonadotropin (hCG) trigger on the clinical pregnancy rate (CPR) in infertile women undergoing intrauterine insemination (IUI) with oral ovulogens. Settings and Design: Retrospective analysis at a tertiary care in vitro fertilization center. Materials and Methods: The records of 280 infertile women, who underwent IUI with oral ovulogens were analyzed. Women who received 0.2 mg triptorelin (GnRH agonist (GnRHa)) as trigger were categorised in Group A (n = 129) and those who received 10,000 IU urinary hCG in Group B (n = 151). The outcome in terms of CPR was studied. Statistical Analysis Used: The quantitative variables were compared using the independent t-test/Mann–Whitney test. The qualitative variables were compared using the Chi-square test. P < 0.05 was considered statistically significant. Results: There was a trend toward better CPR in Group A (21/129 – 16.28%) than in Group B (16/151 – 10.60%), although the difference was not found to be statistically significant (P – 0.162). Conclusions: There was a trend toward better CPR with the use of GnRH agonist trigger in IUI cycles with oral ovulogens in comparison to hCG trigger, although the difference was not found to be statistically significant. Further randomized controlled trials are needed to confirm these findings.
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Affiliation(s)
- Rashmi Sharma
- IVF and Reproductive medicine, Origyn fertility and IVF, 4 floor HB Twin Tower-2 NSP Near D Mall, Pitampura New Delhi -110 034, India
| | - Imlesh Meena
- IVF and Reproductive medicine, Origyn fertility and IVF, 4 floor HB Twin Tower-2 NSP Near D Mall, Pitampura New Delhi -110 034, India
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9
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Abstract
PURPOSE OF REVIEW In a conventional IVF cycle, final oocyte maturation and ovulation is triggered with a bolus of hCG, followed by progesterone-based luteal support that spans several weeks if pregnancy is achieved. This article summarizes several approaches of the exogenous progesterone-free luteal support in IVF. RECENT FINDINGS Triggering ovulation with GnRH agonist may serve as an alternative to hCG, with well established advantages. In addition, the luteal phase can be individualized in order to achieve a more physiologic hormonal milieu, and a more patient friendly treatment, alleviating the burden of a lengthy exogenous progesterone therapy. SUMMARY GnRH agonist trigger followed by a 'freeze all' policy is undoubtedly the best approach towards the 'OHSS-free clinic'. If fresh embryo transfer is considered well tolerated after GnRH agonist trigger, rescue of the corpora lutea by LH activity supplementation is mandatory. Herein we discuss the different approaches of corpus luteum rescue.
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Affiliation(s)
- Shahar Kol
- IVF Unit, Elisha Hospital, Haifa, Israel
| | - Peter Humaidan
- The Fertility Clinic, Skive Regional Hospital, Skive
- Faculty of Health, Aarhus University, Aarhus
- Faculty of Health, University of Southern Denmark, Odense, Denmark
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10
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Gleicher N, Weghofer A, Darmon SK, Barad DH. Rate of rebound in follicle growth after cessation of ovarian stimulation in initial non-responders: a prospective cohort study. J Ovarian Res 2021; 14:11. [PMID: 33422140 PMCID: PMC7797149 DOI: 10.1186/s13048-021-00765-5] [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: 06/08/2020] [Accepted: 01/01/2021] [Indexed: 11/10/2022] Open
Abstract
Previously anecdotally observed rebounds in follicle growth after interruption of exogenous gonadotropins in absolute non-responders were the impetus for here reported study. In a prospective cohort study, we investigated 49 consecutive patients, absolutely unresponsive to maximal exogenous gonadotropin stimulation, for a so-called rebound response to ovarian stimulation. A rebound response was defined as follicle growth following complete withdrawal of exogenous gonadotropin stimulation after complete failure to respond to maximal gonadotropin stimulation over up to 5–7 days. Median age of study patients was 40.5 ± 5.1 years (range 23–52). Women with and without rebound did not differ significantly (40.0 ± 6.0 vs. 41.0 ± 7.0 years, P = 0.41), with 24 (49.0%) recording a rebound and 25 (51.0%) not. Among the former, 21 (87.5%) reached retrieval of 1–3 oocytes and 15 (30.6%) reached embryo transfer. A successful rebound in almost half of prior non-responders was an unsuspected response rate, as was retrieval of 1–3 oocytes in over half of rebounding patients. Attempting rebounds may, thus, represent another incremental step in very poor prognosis patients before giving up on utilization of autologous oocytes. Here presented findings support further investigations into the underlying physiology leading to such an unexpectedly high rebound rate.
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Affiliation(s)
- Norbert Gleicher
- The Center for Human Reproduction, 10021, New York, NY, USA. .,Foundation for Reproductive Medicine, 10021, New York, NY, USA. .,Stem Cell Biology and Molecular Embryology Laboratory, The Rockefeller University, 10016, New York, NY, USA. .,Department of Obstetrics and Gynecology, Vienna University of Medicine, 1090, Vienna, Austria.
| | - Andrea Weghofer
- The Center for Human Reproduction, 10021, New York, NY, USA.,Department of Obstetrics and Gynecology, Vienna University of Medicine, 1090, Vienna, Austria
| | - Sarah K Darmon
- The Center for Human Reproduction, 10021, New York, NY, USA
| | - David H Barad
- The Center for Human Reproduction, 10021, New York, NY, USA.,Foundation for Reproductive Medicine, 10021, New York, NY, USA
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Aflatoonian A, Haghighi F, Hoseini M, Haghdani S. Does the repeat dose of gonadotropin-releasing hormone agonist trigger in polycystic ovarian syndrome improve in vitro fertilization cycles outcome? A clinical trial study. Int J Reprod Biomed 2020; 18:485-490. [PMID: 32803113 PMCID: PMC7385917 DOI: 10.18502/ijrm.v13i7.7363] [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: 09/21/2019] [Revised: 12/30/2019] [Accepted: 01/28/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND A repeat dose of Gonadotropin-releasing Hormone (GnRH) agonist could provide long duration of luteinizing hormone (LH) surge and amplitude appropriately. OBJECTIVE Improvement in oocyte maturity could be obtained by a repeat dose of GnRH agonist. MATERIALS AND METHODS In this randomized double-blinded study, 120 women with polycystic ovarian syndrome and serum estradiol level (E2) > 3000 who were candidate for in vitro fertilization with Antagonist protocol were enrolled between July 2018 and July 2019. Participants were randomized in two groups - and final oocyte maturation was triggered with two doses: In group A, a repeat dose of 0.1 mg, 12 hr. after the first dose and in group B, 0.2 mg SC triptorelin (decapeptyl) 35 hr. prior to oocyte retrieval. Serum Estradiol, LH, and progesterone concentration were measured on the trigger day. Serum LH measurement was done three times in both groups. The outcomes were oocyte yield, meiosis (M) I, MII, Maturity rate, germinal vesicle (GV) rate, 2 pronuclear, embryo yield, ovarian hyper stimulation syndrome rates. RESULTS Maturity rate (p = 0.89), MI (p = 0.38), MII (p = 0.89), and GV oocytes (p = 0.38) were not statistically different between the two study groups. LH levels measured at 12 hr post-trigger did not relate statistically significant with maturity rate in our participants (p = 0.96). No empty follicular syndrome was reported. CONCLUSION Although, the second dose of GnRH agonist after 12 hr since the first dose could provide duration of LH surge and amplitude and as a result no empty follicular syndrome was seen, the maturity rate, MI, MII, and GV oocytes were not different between the two study groups.
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Affiliation(s)
- Abbas Aflatoonian
- Department of Obstetrics and Gynecology, Research and Clinical Center for Infertility, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Science, Yazd, Iran.
| | - Fatemeh Haghighi
- Department of Obstetrics and Gynecology, Research and Clinical Center for Infertility, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Science, Yazd, Iran.
| | - Masrooreh Hoseini
- Department of Obstetrics and Gynecology, Research and Clinical Center for Infertility, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Science, Yazd, Iran.
| | - Saeid Haghdani
- Department of Urology, Hasheminejad Kidney Research Center (HKRC), Iran University of Medical Science, Tehran, Iran.
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Tan J, Jing C, Zhang L, Lo J, Kan A, Nakhuda G. GnRH triggering may improve euploidy and live birth rate in hyper-responders: a retrospective cohort study. J Assist Reprod Genet 2020; 37:1939-1948. [PMID: 32533431 DOI: 10.1007/s10815-020-01842-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 05/22/2020] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Despite the increasing use of GnRHa to trigger final oocyte maturation in segmented IVF cycles, the effects of trigger modality on chromosomal competence and embryo quality remain controversial. Hence, the purpose of this study was to compare euploidy rates and pregnancy outcomes among hyper-responding women using hCG versus GnRHa trigger. METHODS This retrospective study included 333 hyper-responders, defined as >15 oocytes retrieved, who underwent preimplantation genetic testing (PGT-A) in segmented IVF cycles using either GnRHa or urinary hCG trigger. Live birth rate (LBR) was the primary outcome of interest. Implantation rate (IR), clinical pregnancy rate (CPR), and euploidy rate were secondary outcomes. RESULTS GnRH triggering was associated with improved IR (70.5 vs. 53.2%, p = 0.0475), LBR (51.3 vs. 33.8%, p = 0.0170) compared to hCG. A greater number of oocytes were retrieved (21.9 vs 18.4%, p < 0.001) and euploid embryos produced (2.8 vs. 2.1, p = 0.0109) after GnRHa triggering, while higher euploidy rates were only observed among women <35-years-old (62.0 vs. 51.7%, p = 0.0307) using GnRHa trigger. Higher OHSS rates were observed after hCG triggering (10.6 vs. 2.1%, p = 0.0009). CONCLUSION Hyper-responders who received GnRHa trigger experienced improved pregnancy outcomes and lower rates of OHSS compared to hCG triggering. The higher number of oocytes retrieved and euploid embryos produced may reflect an improved developmental competence using GnRHa triggering due to physiologic induction of both LH and FSH surge or other undefined mechanisms that improve embryo development. However, higher overall euploid rates were only observed among women <35-years-old using the GnRHa trigger. Further prospective studies are required to validate this observation and evaluate the specific influence of different ovulation triggers on gamete developmental competence among hyper-responder women.
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Affiliation(s)
- Justin Tan
- Department of Obstetrics and Gynecology, Children's and Women's Hospital and Health Centre of British Columbia, University of British Columbia, D415A-4500 Oak Street, Vancouver, BC, V6H 3N1, Canada.
| | - Chen Jing
- Olive Fertility Centre, Vancouver, BC, Canada
| | - Lisa Zhang
- Department of Obstetrics and Gynecology, Children's and Women's Hospital and Health Centre of British Columbia, University of British Columbia, D415A-4500 Oak Street, Vancouver, BC, V6H 3N1, Canada
| | - Jasmine Lo
- Department of Obstetrics and Gynecology, Children's and Women's Hospital and Health Centre of British Columbia, University of British Columbia, D415A-4500 Oak Street, Vancouver, BC, V6H 3N1, Canada
| | - Arohumam Kan
- Department of Obstetrics and Gynecology, Children's and Women's Hospital and Health Centre of British Columbia, University of British Columbia, D415A-4500 Oak Street, Vancouver, BC, V6H 3N1, Canada
| | - Gary Nakhuda
- Department of Obstetrics and Gynecology, Children's and Women's Hospital and Health Centre of British Columbia, University of British Columbia, D415A-4500 Oak Street, Vancouver, BC, V6H 3N1, Canada
- Olive Fertility Centre, Vancouver, BC, Canada
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Padmanabhan V, Cardoso RC. Neuroendocrine, autocrine, and paracrine control of follicle-stimulating hormone secretion. Mol Cell Endocrinol 2020; 500:110632. [PMID: 31682864 PMCID: PMC7433377 DOI: 10.1016/j.mce.2019.110632] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/24/2019] [Accepted: 10/25/2019] [Indexed: 12/12/2022]
Abstract
Follicle-stimulating hormone (FSH) is a glycoprotein hormone produced by gonadotropes in the anterior pituitary that plays a central role in controlling ovarian folliculogenesis and steroidogenesis in females. Moreover, recent studies strongly suggest that FSH exerts extragonadal actions, particularly regulating bone mass and adiposity. Despite its crucial role, the mechanisms regulating FSH secretion are not completely understood. It is evident that hypothalamic, ovarian, and pituitary factors are involved in the neuroendocrine, paracrine, and autocrine regulation of FSH production. Large animal models, such as the female sheep, represent valuable research models to investigate specific aspects of FSH secretory processes. This review: (i) summarizes the role of FSH controlling reproduction and other biological processes; (ii) discusses the hypothalamic, gonadal, and pituitary regulation of FSH secretion; (iii) considers the biological relevance of the different FSH isoforms; and (iv) summarizes the distinct patterns of FSH secretion under different physiological conditions.
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14
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Evaluation of uterine receptivity after gonadotropin releasing hormone agonist administration as an oocyte maturation trigger: a rodent model. Sci Rep 2019; 9:12519. [PMID: 31467307 PMCID: PMC6715633 DOI: 10.1038/s41598-019-48918-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 08/12/2019] [Indexed: 01/16/2023] Open
Abstract
In natural cycle or minimal stimulation cycle IVF, buserelin acetate (buserelin), a gonadotropin-releasing hormone agonist, is often used as a maturation trigger; however, its effect on pregnancy outcomes remains unclear. Therefore, in the present study, we compared uterine receptivity in buserelin-administered mice with that in human chorionic gonadotropin (hCG)-administered mice during the peri-implantation period. Implantation, decidualisation, and term-pregnancy were impaired following hCG, but not buserelin administration. hCG stimulated the synthesis and secretion of progesterone and oestradiol, whereas ovarian steroidogenesis in the buserelin-treated group was comparable with that in the control group. Furthermore, similar to the observation in controls, the buserelin-treated group exhibited activation of progesterone receptor signalling and inhibition of oestrogen receptor signalling in the endometrial epithelium on the day of implantation. However, epithelial progesterone signalling was not detected, and a high expression of genes downstream to oestrogen was observed on day 4 following hCG administration. These results suggest that buserelin administration does not impact uterine receptivity as it did not affect ovarian steroidogenesis and endometrial steroid signalling. Therefore, buserelin is preferred as an oocyte maturation trigger to optimise uterine receptivity during treatments involving timed intercourse, intrauterine insemination, or fresh embryo transfer following in vitro fertilisation.
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15
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Comparison of GnRH agonist and hCG for priming in vitro maturation cycles in cancer patients undergoing urgent fertility preservation. PLoS One 2018; 13:e0208576. [PMID: 30521621 PMCID: PMC6283534 DOI: 10.1371/journal.pone.0208576] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 11/20/2018] [Indexed: 11/20/2022] Open
Abstract
In vitro maturation (IVM) of oocytes retrieved at germinal vesicle or Metaphase I stage, followed by vitrification of Metaphase II (MII) oocytes, has recently emerged as an option for urgent fertility preservation (FP). Priming is usually achieved with an injection of hCG, 10,000 IU, 36 hours before retrieval. This study aimed to assess a new method of priming, using GnRH agonists, and compare it to hCG, in cancer patients undergoing urgent FP. From 2009 to 2015, 373 cancer patients underwent MII oocyte cryopreservation after IVM cycles primed either with GnRHa (triptorelin 0.2 mg) (n = 138) or hCG (10,000 IU) (n = 235). Patients’ characteristics were comparable between the two groups. The number of COC retrieved was significantly higher in the GnRHa group (9.1 ± 6.8 versus 7.7 ± 5.5 oocytes, p = 0.04). However, the maturation rates (59 ±25% versus 64 ±26%, p = 0.07, respectively), and the total number of MII oocytes frozen (5.2 ±4.2 versus 4.9 ±4.0, p = 0.6, respectively) were similar between the GnRha and hCG groups. We did not find any difference between GnRHa and hCG priming for IVM. GnRHa priming is more physiological since it stimulates endogenous FSH and LH activity, and is well suited for FP in hormone-sensitive cancers and urgent cases.
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16
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Haahr T, Esteves SC, Humaidan P. Poor definition of poor-ovarian response results in misleading clinical recommendations. Hum Reprod 2018; 33:979-980. [DOI: 10.1093/humrep/dey059] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 03/02/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Thor Haahr
- Department of Clinical Medicine, Aarhus University, Denmark and the Fertility Clinic Skive, Skive Regional Hospital, Resenvej 25, 7800 Skive, Denmark
| | - Sandro C Esteves
- Department of Clinical Medicine, Aarhus University, Denmark and the Fertility Clinic Skive, Skive Regional Hospital, Resenvej 25, 7800 Skive, Denmark
- ANDROFERT, Andrology and Human Reproduction Clinic, 13075-460 Campinas, SP, Brazil
- Department of Surgery, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Peter Humaidan
- Department of Clinical Medicine, Aarhus University, Denmark and the Fertility Clinic Skive, Skive Regional Hospital, Resenvej 25, 7800 Skive, Denmark
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Anaya Y, Mata DA, Letourneau J, Cakmak H, Cedars MI, Rosen MP. A novel oocyte maturation trigger using 1500 IU of human chorionic gonadotropin plus 450 IU of follicle-stimulating hormone may decrease ovarian hyperstimulation syndrome across all in vitro fertilization stimulation protocols. J Assist Reprod Genet 2017; 35:297-307. [PMID: 29086322 DOI: 10.1007/s10815-017-1074-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 10/17/2017] [Indexed: 10/18/2022] Open
Abstract
PURPOSE Modification of the trigger used to induce final oocyte maturation in in vitro fertilization (IVF) is a major strategy used to reduce the risk of ovarian hyperstimulation syndrome (OHSS). A novel trigger composed of 1500 IU of human chorionic gonadotropin (hCG) plus 450 IU of follicle-stimulating hormone (FSH) has been developed to reduce OHSS risk. This study compares outcomes of the novel trigger to conventional triggers used in high-risk OHSS patients undergoing IVF. METHODS In this retrospective cohort study, IVF cycles at high risk for OHSS based on a serum estradiol > 5000 pg/ml on trigger day conducted between January 2008 and February 2016 were evaluated. Oocyte maturation was induced with the novel trigger (1500 IU hCG plus 450 IU FSH) or a conventional trigger [3300 IU hCG, gonadotropin-releasing hormone agonist (GnRHa) alone, or GnRHa plus 1500 IU hCG]. IVF cycle outcomes were compared. Trigger strategies were examined for associations with OHSS development using logistic regression. RESULTS Among 298 eligible IVF cycles identified, there were no differences in oocyte maturation, fertilization, embryo quality, or pregnancy outcomes among all triggers. After adjusting for serum estradiol level and number of follicles, the novel trigger was associated with lower odds of OHSS symptom development compared to the 3300 IU hCG and GnRHa plus hCG 1500 IU triggers (p = 0.007 and 0.04, respectively). CONCLUSIONS This study suggests that 1500 IU hCG plus 450 IU FSH may be associated with decreased OHSS symptoms compared to conventional triggers, while producing similar IVF and pregnancy outcomes. More important, this novel trigger may provide a superior alternative in down-regulated cycles and in patients with hypothalamic dysfunction where GnRHa triggers cannot be utilized.
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Affiliation(s)
- Yanett Anaya
- Center for Reproductive Health and Division of Reproductive Endocrinology and Infertility, University of California, San Francisco, 499 Illinois Street, San Francisco, CA, 94143, USA.
| | - Douglas A Mata
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Joseph Letourneau
- Center for Reproductive Health and Division of Reproductive Endocrinology and Infertility, University of California, San Francisco, 499 Illinois Street, San Francisco, CA, 94143, USA
| | - Hakan Cakmak
- Center for Reproductive Health and Division of Reproductive Endocrinology and Infertility, University of California, San Francisco, 499 Illinois Street, San Francisco, CA, 94143, USA
| | - Marcelle I Cedars
- Center for Reproductive Health and Division of Reproductive Endocrinology and Infertility, University of California, San Francisco, 499 Illinois Street, San Francisco, CA, 94143, USA
| | - Mitchell P Rosen
- Center for Reproductive Health and Division of Reproductive Endocrinology and Infertility, University of California, San Francisco, 499 Illinois Street, San Francisco, CA, 94143, USA
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18
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Ding N, Liu X, Jian Q, Liang Z, Wang F. Dual trigger of final oocyte maturation with a combination of GnRH agonist and hCG versus a hCG alone trigger in GnRH antagonist cycle for in vitro fertilization: A Systematic Review and Meta-analysis. Eur J Obstet Gynecol Reprod Biol 2017; 218:92-98. [PMID: 28957685 DOI: 10.1016/j.ejogrb.2017.09.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 08/05/2017] [Accepted: 09/05/2017] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Increasing evidence indicates that a dual trigger (a gonadotrophin-releasing hormone agonist [GnRH-a] with a human chorionic gonadotrophin [hCG] trigger) is the best choice for final oocyte maturation in the GnRH antagonist (GnRH-ant) cycle. However, this conclusion remains controversial. Therefore, we performed this meta-analysis to systematically evaluate the efficacy of a GnRH-a combined with a standard hCG trigger in comparison with hCG alone for final oocyte maturation in the GnRH-ant cycle for in vitro fertilization. STUDY DESIGN Complete electronic databases, including PubMed, Embase, The Cochrane Library, and Web of Science, were searched for relevant randomized controlled trials (RCT). The search was not restricted by language or publication time. Two reviewers selected trials and assessed trial quality independently by using the Cochrane Handbook 5.1.0. RESULTS Four eligible RCT studies involving 527 women were included. The results of this meta-analysis indicated that the dual trigger group had a significantly higher pregnancy rate (relative risk [RR], 1.55; 95% confidence interval [CI], 1.17-2.06) than the hCG-only trigger group. No significant differences were found in the number of oocytes retrieved (weighted mean difference [WMD], 0.47; 95% CI, -0.42 to 1.37), number of mature oocytes retrieved (WMD, 0.41; 95% CI, -0.48 to 1.30), number of fertilized oocytes (WMD, 0.47; 95% CI, -0.32 to 1.26), number of good-quality embryos (WMD, 0.17; 95% CI, -0.29 to 0.64), or implantation rate (RR, 1.17; 95% CI, 0.69-2.00) between the two groups. CONCLUSION GnRH-a and hCG as dual trigger was equivalent to hCG in triggering oocyte maturation and may be beneficial in improving reproductive outcomes. Further intensive randomized-controlled studies should be conducted to investigate the efficacy of the dual trigger.
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Affiliation(s)
- Nan Ding
- Reproductive Medicine Center, Lanzhou University Second Hospital, Gansu, Lanzhou City, 730030, China
| | - Xingchen Liu
- Reproductive Medicine Center, Lanzhou University Second Hospital, Gansu, Lanzhou City, 730030, China
| | - Qiliang Jian
- Reproductive Medicine Center, Lanzhou University Second Hospital, Gansu, Lanzhou City, 730030, China
| | - Zhongzhen Liang
- Reproductive Medicine Center, Lanzhou University Second Hospital, Gansu, Lanzhou City, 730030, China
| | - Fang Wang
- Reproductive Medicine Center, Lanzhou University Second Hospital, Gansu, Lanzhou City, 730030, China.
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Mastrangeli R, Satwekar A, Cutillo F, Ciampolillo C, Palinsky W, Longobardi S. In-vivo biological activity and glycosylation analysis of a biosimilar recombinant human follicle-stimulating hormone product (Bemfola) compared with its reference medicinal product (GONAL-f). PLoS One 2017; 12:e0184139. [PMID: 28880909 PMCID: PMC5589168 DOI: 10.1371/journal.pone.0184139] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Accepted: 08/18/2017] [Indexed: 02/03/2023] Open
Abstract
Recombinant human follicle-stimulating hormone (r-hFSH) is widely used in fertility treatment. Although biosimilar versions of r-hFSH (follitropin alfa) are currently on the market, given their structural complexity and manufacturing process, it is important to thoroughly evaluate them in comparison with the reference product. This evaluation should focus on how they differ (e.g., active component molecular characteristics, impurities and potency), as this could be associated with clinical outcome. This study compared the site-specific glycosylation profile and batch-to-batch variability of the in-vivo bioactivity of Bemfola, a biosimilar follitropin alfa, with its reference medicinal product GONAL-f. The focus of this analysis was the site-specific glycosylation at asparagine (Asn) 52 of the α-subunit of FSH, owing to the pivotal role of Asn52 glycosylation in FSH receptor (FSHR) activation/signalling. Overall, Bemfola had bulkier glycan structures and greater sialylation than GONAL-f. The nominal specific activity for both Bemfola and GONAL-f is 13,636 IU/mg. Taking into account both the determined potency and the nominal amount the average specific activity of Bemfola was 14,522 IU/mg (105.6% of the nominal value), which was greater than the average specific activity observed for GONAL-f (13,159 IU/mg; 97.3% of the nominal value; p = 0.0048), although this was within the range stated in the product label. A higher batch-to-batch variability was also observed for Bemfola versus GONAL-f (coefficient of variation: 8.3% vs 5.8%). A different glycan profile was observed at Asn52 in Bemfola compared with GONAL-f (a lower proportion of bi-antennary structures [~53% vs ~77%], and a higher proportion of tri-antennary [~41% vs ~23%] and tetra-antennary structures [~5% vs <1%]). These differences in the Asn52 glycan profile might potentially lead to differences in FSHR activation. This, together with the greater bioactivity and higher batch-to-batch variability of Bemfola, could partly explain the reported differences in clinical outcomes. The clinical relevance of the differences observed between GONAL-f and Bemfola should be further investigated.
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Affiliation(s)
- Renato Mastrangeli
- Biotech Development Programme, Merck Serono S.p.A. (an affiliate of Merck KGaA, Darmstadt, Germany), Guidonia Montecelio, Rome, Italy
- * E-mail:
| | - Abhijeet Satwekar
- Pharamceutical & Analytical Development Biotech Products, Merck Serono S.p.A. (an affiliate of Merck KGaA, Darmstadt, Germany), Guidonia Montecelio, Rome, Italy
| | - Francesca Cutillo
- Pharamceutical & Analytical Development Biotech Products, Merck Serono S.p.A. (an affiliate of Merck KGaA, Darmstadt, Germany), Guidonia Montecelio, Rome, Italy
| | - Cinzia Ciampolillo
- Analytical BQC, Merck RBM S.p.A. (an affiliate of Merck KGaA, Darmstadt, Germany), Ivrea, Turin, Italy
| | - Wolf Palinsky
- Biotech Development Programme, Merck Biopharma (an affiliate of Merck KGaA, Darmstadt, Germany), Aubonne, Switzerland
| | - Salvatore Longobardi
- Global Medical Affairs Fertility, Merck Serono S.p.A. (an affiliate of Merck KGaA, Darmstadt, Germany), Guidonia Montecelio, Rome, Italy
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Cruz M, Alamá P, Muñoz M, Collado D, Blanes C, Solbes E, Requena A. Economic impact of ovarian stimulation with corifollitropin alfa versus conventional daily gonadotropins in oocyte donors: a randomized study. Reprod Biomed Online 2017; 34:605-610. [DOI: 10.1016/j.rbmo.2017.03.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 03/09/2017] [Accepted: 03/09/2017] [Indexed: 11/26/2022]
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Alyasin A, Mehdinejadiani S, Ghasemi M. GnRH agonist trigger versus hCG trigger in GnRH antagonist in IVF/ICSI cycles: A review article. Int J Reprod Biomed 2016. [DOI: 10.29252/ijrm.14.9.557] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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De Leo V, Musacchio MC, Cappelli V, Piomboni P, Morgante G. Hormonal contraceptives: pharmacology tailored to women's health. Hum Reprod Update 2016; 22:634-46. [PMID: 27307386 DOI: 10.1093/humupd/dmw016] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 01/29/2016] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND In recent years, several new oral contraceptives have become available. In some ways, they represent an evolution in terms of individualization and compliance on the part of women. The new formulations make it increasingly possible to prescribe a specific hormonal contraceptive on an individual basis. METHODS A systematic literature search of PubMed was performed using the following combination of terms: 'oral contraceptives', 'estroprogestins' and 'combined oral contraceptive'. Only English-language papers published between January 2000 and July 2014 were included in our analysis. The present review analyzes all aspects of the choice of oral contraceptives in the different phases of a woman's life in detail. RESULTS Regarding the estrogen component, lowering the dose of ethinylestradiol (EE) helped reduce associated side effects. Natural estradiol is now available and represents a valid alternative to EE. And regarding progestins, the dose has changed over time, as well as the endocrine and metabolic characteristics. These are the fruit of much research into improvement of old products (19-nor-progesterone-derived progestins) with androgenic effects and testing of new molecules with improved metabolic neutrality in terms of insulin sensitivity and lipid parameters. New progestins were a genuine turning point because they greatly reduced major side effects, such as water retention, and their anti-androgenic properties made them indicated for all forms of hyperandrogenism associated with acne and mild hirsutism. The associations of estradiol/dienogest and estradiol/nomegestrol acetate are the most suitable contraceptives for women with abundant menstrual bleeding and can increase the number of potential users of hormonal contraception. CONCLUSION Progress in the provision of new oral contraceptives has improved the risk/benefit ratio, by increasing benefits and reducing risks. The present challenge is to tailor contraceptives to individual needs in terms of efficacy and protection of reproductive health.
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Affiliation(s)
- Vincenzo De Leo
- Department of Molecular and Developmental Medicine, University of Siena, Policlinico Le Scotte, Viale Bracci 14, 53100 Siena, Italy
| | - Maria Concetta Musacchio
- Department of Molecular and Developmental Medicine, University of Siena, Policlinico Le Scotte, Viale Bracci 14, 53100 Siena, Italy
| | - Valentina Cappelli
- Department of Molecular and Developmental Medicine, University of Siena, Policlinico Le Scotte, Viale Bracci 14, 53100 Siena, Italy
| | - Paola Piomboni
- Department of Molecular and Developmental Medicine, University of Siena, Policlinico Le Scotte, Viale Bracci 14, 53100 Siena, Italy
| | - Giuseppe Morgante
- Department of Molecular and Developmental Medicine, University of Siena, Policlinico Le Scotte, Viale Bracci 14, 53100 Siena, Italy
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Seval MM, Özmen B, Atabekoğlu C, Şükür YE, Şimşir C, Kan Ö, Sönmezer M. Dual trigger with gonadotropin-releasing hormone agonist and recombinant human chorionic gonadotropin improves in vitro fertilization outcome in gonadotropin-releasing hormone antagonist cycles. J Obstet Gynaecol Res 2016; 42:1146-51. [PMID: 27199084 DOI: 10.1111/jog.13021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 02/15/2016] [Accepted: 03/12/2016] [Indexed: 11/28/2022]
Abstract
AIM The aim of this study was to evaluate whether dual trigger with leuprolide acetate plus recombinant human chorionic gonadotropin (hCG) improves in vitro fertilization outcome in gonadotropin-releasing hormone antagonist cycles. METHODS A total of 156 patients diagnosed with mild male factor, unexplained or tubal factor infertility were enrolled in the study. All subjects were allocated into one of two groups: the dual trigger group (leuprolide acetate 500 μg + recombinant hCG 250 μg) and the standard group (recombinant hCG 250 μg) according to the selected trigger method. Oocyte trigger was performed when at least three follicles >17 mm were observed. Pregnancy rate, number of collected oocytes, number of metaphase II oocytes, number of grade-A embryos, cycle cancellation rate, and ovarian hyperstimulation syndrome rate were the main outcome measures for the study. RESULTS The mean number of grade-A embryos (1.6 ± 1.5 vs 1.1 ± 1.4, P = 0.01) and of metaphase II oocytes (7.9 ± 4.6 vs 6.3 ± 5.8, P = 0.02) was significantly higher in the dual-trigger group. Pregnancy rate was significantly higher in the dual-trigger group than in the standard group (54.8 vs 37.5%, P = 0.006). Two cases of mild ovarian hyperstimulation syndrome were observed in each group. CONCLUSION This novel and more physiological trigger approach using 500 μg leuprolide acetate plus 250 μg recombinant hCG may lead to an increase in the number of metaphase II oocytes, grade-A embryos, and may improve pregnancy rates.
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Affiliation(s)
- Mehmet Murat Seval
- Department of Obstetrics and Gynecology, Center for Research on Human Reproduction, Ankara University Medical Faculty, Ankara, Turkey.
| | - Batuhan Özmen
- Department of Obstetrics and Gynecology, Center for Research on Human Reproduction, Ankara University Medical Faculty, Ankara, Turkey
| | - Cem Atabekoğlu
- Department of Obstetrics and Gynecology, Center for Research on Human Reproduction, Ankara University Medical Faculty, Ankara, Turkey
| | - Yavuz Emre Şükür
- Department of Obstetrics and Gynecology, Center for Research on Human Reproduction, Ankara University Medical Faculty, Ankara, Turkey
| | | | - Özgur Kan
- Department of Obstetrics and Gynecology, Center for Research on Human Reproduction, Ankara University Medical Faculty, Ankara, Turkey
| | - Murat Sönmezer
- Department of Obstetrics and Gynecology, Center for Research on Human Reproduction, Ankara University Medical Faculty, Ankara, Turkey
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Engmann L, Benadiva C, Humaidan P. GnRH agonist trigger for the induction of oocyte maturation in GnRH antagonist IVF cycles: a SWOT analysis. Reprod Biomed Online 2016; 32:274-85. [PMID: 26803205 DOI: 10.1016/j.rbmo.2015.12.007] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Revised: 12/19/2015] [Accepted: 12/22/2015] [Indexed: 01/26/2023]
Abstract
Gonadotrophin releasing hormone agonist (GnRHa) trigger is effective in the induction of oocyte maturation and prevention of ovarian hyperstimulation syndrome during IVF treatment. This trigger concept, however, results in early corpora lutea demise and consequently luteal phase dysfunction and impaired endometrial receptivity. The aim of this strenghths, weaknesses, opportunities and threats analysis was to summarize the progress made over the past 15 years to optimize ongoing pregnancy rates after GnRHa trigger. The advantages and potential drawbacks of this type of triggering are reviewed. The current approach to the management of GnRHa trigger in autologous cycles is based on the peak serum oestradiol level or follicle number and aims at a fresh embryo transfer or a segmentation approach with elective cryopreservation policy. We recommend intensive luteal support with transdermal oestradiol and intramuscular progesterone alone if peak serum oestradiol is 4000 or more pg/ml after GnRHa trigger or dual trigger with GnRHa and HCG 1000 IU if peak serum oestradiol is less than 4000 pg/mL. On the contrary, we recommend HCG 1500 IU 35 h after GnRHa trigger if there are less than 25 follicles, or freeze all oocytes or embryos if there are over 25 follicles.
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Affiliation(s)
- Lawrence Engmann
- Department of Obstetrics and Gynecology, Center for Advanced Reproductive Services, University of Connecticut School of Medicine, 2 Batterson Park Road, Farmington, CT, USA.
| | - Claudio Benadiva
- Department of Obstetrics and Gynecology, Center for Advanced Reproductive Services, University of Connecticut School of Medicine, 2 Batterson Park Road, Farmington, CT, USA
| | - Peter Humaidan
- The Fertility Clinic, Skive Regional Hospital and Faculty of Health, Aarhus University, Resenvej 25, 7800 Skive, Denmark
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Vuong TNL, Ho MT, Ha TD, Phung HT, Huynh GB, Humaidan P. Gonadotropin-releasing hormone agonist trigger in oocyte donors co-treated with a gonadotropin-releasing hormone antagonist: a dose-finding study. Fertil Steril 2015; 105:356-63. [PMID: 26523330 DOI: 10.1016/j.fertnstert.2015.10.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 10/07/2015] [Accepted: 10/13/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To determine the optimal GnRH agonist dose for triggering of oocyte maturation in oocyte donors. DESIGN Single-center, randomized, parallel, investigator-blinded trial. SETTING IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam. PATIENT(S) One hundred sixty-five oocyte donors (aged 18-35 years, body mass index [BMI] <28 kg/m(2), antimüllerian hormone level >1.25 ng/mL, and antral follicle count ≥6). INTERVENTION(S) Ovulation trigger with 0.2, 0.3, or 0.4 mg triptorelin in a GnRH antagonist cycle. MAIN OUTCOME MEASURE(S) The primary end point was number of metaphase II oocytes. Secondary end points were fertilization and cleavage rates, number of embryos and top-quality embryos, steroid levels, ovarian volume, and ongoing pregnancy rate (PR) in recipients. RESULT(S) There were no significant differences between the triptorelin 0.2, 0.3, and 0.4 mg trigger groups with respect to number of metaphase II oocytes (16.0 ± 8.5, 15.9 ± 7.8, and 14.7 ± 8.4, respectively), embryos (13.2 ± 7.8, 11.7 ± 6.9, 11.8 ± 7.0), and number of top-quality embryos (3.8 ± 2.9, 3.6 ± 3.0, 4.1 ± 3.0). Luteinizing hormone levels at 24 hours and 36 hours after trigger was significantly higher with triptorelin 0.4 mg versus 0.2 mg and 0.3 mg (9.8 ± 7.1 IU/L vs. 7.3 ± 4.1 IU/L and 7.2 ± 3.7 IU/L, respectively; 4.6 ± 3.2 IU/L vs. 3.2 ± 2.3 IU/L and 3.3 ± 2.1 IU/L, respectively. Progesterone level at oocyte pick-up +6 days was significantly higher in the 0.4-mg group (2.2 ± 3.7 ng/ml) versus 0.2 mg (1.1 ± 1.0 ng/ml) and 0.3 mg (1.2 ± 1.6 ng/ml). One patient developed early-onset severe ovarian hyperstimulation syndrome (OHSS). CONCLUSION(S) No significant differences between triptorelin doses of 0.2, 0.3, and 0.4 mg used for ovulation trigger in oocyte donors were seen with regard to the number of mature oocytes and top-quality embryos. CLINICAL TRIAL REGISTRATION NUMBER NCT02208986.
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Affiliation(s)
- Thi Ngoc Lan Vuong
- Department of Obstetrics and Gynaecology, University of Medicine and Pharmacy HCMC, Ho Chi Minh City, Vietnam; IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam.
| | - Manh Tuong Ho
- IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam; Research Center for Genetics and Reproductive Health (CGRH), School of Medicine, Vietnam National University HCMC, Ho Chi Minh City, Vietnam
| | - Tan Duc Ha
- National Hospital of Can Tho, Ho Chi Minh City, Vietnam; Ton Duc Thang University, Ho Chi Minh City, Vietnam
| | | | | | - Peter Humaidan
- The Fertility Clinic, Skive Regional Hospital, Aarhus, Denmark; Faculty of Health, Aarhus University and Faculty of Health, University of Southern Denmark, Aarhus, Denmark
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Türkgeldi E, Türkgeldi L, Seyhan A, Ata B. Gonadotropin-releasing hormone agonist triggering of oocyte maturation in assisted reproductive technology cycles. Turk J Obstet Gynecol 2015; 12:96-101. [PMID: 28913051 PMCID: PMC5558384 DOI: 10.4274/tjod.92979] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 06/30/2015] [Indexed: 12/04/2022] Open
Abstract
Gonadotropin-releasing hormone agonists (GnRHa) have gained increasing attention in the last decade as an alternative trigger for oocyte maturation in patients at high risk for ovarian hyperstimulation syndrome (OHSS). They provide a short luteinizing hormone (LH) peak that limits the production of vascular endothelial growth factor, which is the key mediator leading to increased vascular permeability, the hallmark of OHSS. Initial studies showed similar oocyte yield and embryo quality compared with conventional human chorionic gonadotropin (hCG) triggering; however, lower pregnancy rates and higher miscarriage rates were alarming in GnRHa triggered groups. Therefore, two approaches have been implemented to rescue the luteal phase in fresh transfers. Intensive luteal phase support (iLPS) involves administiration of high doses of progesterone and estrogen and active patient monitoring. iLPS has been shown to provide satisfactory fertilization and clinical pregnancy rates, and to be especially useful in patients with high endogenous LH levels, such as in polycystic ovary syndrome. The other method for luteal phase rescue is low-dose hCG administiration 35 hours after GnRHa trigger. Likewise, this method results in statistically similar ongoing pregnancy rates (although slightly lower than) to those of hCG triggered cycles. GnRHa triggering decreased OHSS rates dramatically, however, none of the rescue methods prevent OHSS totally. Cases were reported even in patients who underwent cryopreservation and did not receive hCG. GnRH triggering induces a follicle stimulating hormone (FSH) surge, similar to natural cycles. Its possible benefits have been investigated and dual triggering, GnRHa trigger accompanied by a simultaneous low-dose hCG injection, has produced promising results that urge further exploration. Last of all, GnRHa triggering is useful in fertility preservation cycles in patients with hormone sensitive tumors. In conclusion, GnRHa triggering accompanied by appropriate luteal phase rescue protocols is a relatively safe option for patients at high risk for OHSS.
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Affiliation(s)
- Engin Türkgeldi
- Koç University Hospital, Department of Obstetrics and Gynecology, İstanbul, Turkey
| | - Lale Türkgeldi
- Kanuni Sultan Süleyman Research and Teaching Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Ayşe Seyhan
- American Hospital, Assisted Reproduction Unit, İstanbul, Turkey
| | - Barış Ata
- Koç University Faculty of Medicine, Department of Obstetrics and Gynecology, İstanbul, Turkey
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Major drawbacks and additional benefits of agonist trigger—not ovarian hyperstimulation syndrome related. Fertil Steril 2015; 103:874-8. [DOI: 10.1016/j.fertnstert.2015.01.035] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 01/21/2015] [Accepted: 01/22/2015] [Indexed: 11/18/2022]
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Atkinson P, Koch J, Susic D, Ledger WL. GnRH agonist triggers and their use in assisted reproductive technology: the past, the present and the future. ACTA ACUST UNITED AC 2015; 10:267-76. [PMID: 24956293 DOI: 10.2217/whe.14.14] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Gonadotropin releasing hormone agonist triggers are very effective in eliminating early-onset ovarian hyperstimulation syndrome (OHSS). However, in most studies they result in inferior pregnancy rates compared to hCG triggers in fresh autologous transfers. This is not due to an effect on embryo quality but rather due to inadequate corpus luteum formation and a defective luteal phase causing poor implantation. Intensive and adjusted steroid support or low-dose hCG may correct this. Late-onset OHSS is eliminated by using a freeze-all strategy. Pregnancy rates after transfer of thawed vitrified embryos are consistently high. A strategy combining a gonadotropin releasing hormone agonist trigger with vitrification of all embryos has been proposed as a means of achieving a truly OHSS-free clinic.
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Soliman BS, Siam S. Pregnancy rate after ovulation triggering with gonadotrophin releasing hormone agonist versus human chorionic gonadotrophin in women undergoing controlled ovarian stimulation/intrauterine insemination. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2014. [DOI: 10.1016/j.mefs.2013.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Borgbo T, Jeppesen J, Lindgren I, Lundberg Giwercman Y, Hansen L, Yding Andersen C. Effect of the FSH receptor single nucleotide polymorphisms (FSHR 307/680) on the follicular fluid hormone profile and the granulosa cell gene expression in human small antral follicles. ACTA ACUST UNITED AC 2014; 21:255-61. [DOI: 10.1093/molehr/gau106] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Use of gonadotropin-releasing hormone agonist trigger during in vitro fertilization is associated with similar endocrine profiles and oocyte measures in women with and without polycystic ovary syndrome. Fertil Steril 2014; 103:264-9. [PMID: 25450300 DOI: 10.1016/j.fertnstert.2014.09.042] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 09/27/2014] [Accepted: 09/30/2014] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To compare endocrine profiles and IVF outcomes after using GnRH agonists (GnRHa) to trigger final oocyte maturation in women with polycystic ovary syndrome (PCOS) with other hyper-responders. DESIGN Retrospective cohort study. SETTING Academic center. PATIENT(S) Forty women with PCOS and 74 hyper-responders without PCOS. INTERVENTION(S) GnRHa trigger. MAIN OUTCOME MEASURE(S) Number of oocytes. RESULT(S) Serum E2, LH, and P levels on the day of GnRHa trigger and the day after trigger did not differ significantly between groups. There were no significant differences in total number of oocytes or percent mature oocytes obtained between groups after controlling for age, antral follicle count, and total days of stimulation. The overall rate of no retrieval of oocytes after trigger was low (2.6%). Fertilization, implantation, clinical pregnancy, and live-birth rates were similar in the two groups. No patients developed ovarian hyperstimulation syndrome (OHSS). CONCLUSION(S) The similar post-GnRHa trigger hormone profiles and mature oocyte yield support the routine use of GnRHa trigger to prevent OHSS in women with PCOS.
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Sequential (hFSH + recFSH) vs homogenous (hFSH or recFSH alone) stimulation: clinical and biochemical (cumulus cell gene expression) aspects. J Assist Reprod Genet 2014; 31:657-65. [PMID: 24639041 DOI: 10.1007/s10815-014-0208-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 02/28/2014] [Indexed: 01/16/2023] Open
Abstract
FSH is a key hormone in the regulation of follicular development. Together with the EGF network, these molecules mediate oocyte maturation and competence in preparation for the action of LH. FSH isoforms regulate distinct biological pathways and have specific effects on granulosa cell function and maturation of the ovarian follicle. Their dynamic interactions occur during the follicular cycle; short-living forms are predominant in the pre-ovulatory phase, whereas long-acting molecules characterize the luteal-follicular transition. Recombinant FSH (rFSH) molecules have a reduced number of isoforms and are less acidic, with a shorter half-life. We have investigated sequential stimulation, comparing hFSH + rFSH, vs. rFSH alone and hFSH alone for the entire stimulation phase. Sequential stimulation leads to an E2 per MII oocyte ratio that is much lower than is seen during treatment with the two drugs individually. Although there is a positive tendency in favor of the sequential treatment, there was no significant difference in pregnancy rates, even taking frozen embryos into consideration. The cumulus cell transcriptome varies considerably between the treatments, although with no clear significance. When comparing pregnant vs. non-pregnant patients, in general a decrease in mRNA expression can be observed in the pregnant patients, especially in expression of folic acid receptor 1 and ovostatin 2. This indicates that material has been transferred from CC to the oocyte. However, a common observation in the literature is that variations in the transcriptome of the cumulus cells are highly dependent upon the patient genotype; the potential for applying this strategy as a basis for selecting embryos is, at the very least, questionable.
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Requena A, Cruz M, Ruiz FJ, García-Velasco JA. Endocrine profile following stimulation with recombinant follicle stimulating hormone and luteinizing hormone versus highly purified human menopausal gonadotropin. Reprod Biol Endocrinol 2014; 12:10. [PMID: 24476504 PMCID: PMC3907361 DOI: 10.1186/1477-7827-12-10] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 01/19/2014] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Luteinizing hormone (LH) activity in human menopausal gonadotropin (hMG) preparations is derived from human chorionic gonadotropin (hCG) rather than LH. Therefore, we aimed to determine whether there are similarities in the endocrine and follicular profiles of serum and follicular fluid from controlled ovarian stimulation with the recombinant gonadotropins follicle-stimulating hormone plus luteinizing hormone (rFSH + rLH) or highly purified human menopausal gonadotropin (HP-hMG). METHODS We performed a prospective observational study with 50 oocyte donors that received either a combination of recombinant gonadotropins (rFSH + rLH) or a mixture of urinary gonadotropins (HP-hMG) plus purified urinary FSH (uFSH). Results were analyzed using Student's t-test to compare continuous variables and the chi-squared test to compare proportions. P-values < 0.05 were considered statistically significant. RESULTS Although more oocytes were retrieved after treatment with recombinant than urinary gonadotropins (16.5 vs. 11.8; P = 0.049), a higher proportion of metaphase II ova (71.2% vs. 80.6%; P = 0.003) were obtained using urinary gonadotropins. On day 6 and on the day of triggering, serum steroid hormone levels were slightly but not significantly elevated in the recombinant group compared with the urinary group. In follicular fluid, no statistical differences were observed for intra-follicular levels of steroid hormones between the two protocols; ongoing pregnancy rates were similar (46.1% vs. 46.1%). CONCLUSIONS Our data suggest that endocrinological and follicular profiles do not differ between rFSH + rLH and HP-hMG stimulation.
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Affiliation(s)
- Antonio Requena
- Reproductive Medicine Department, Instituto Valenciano de Infertilidad IVI Madrid, Avenida del Talgo 68-70, Aravaca, Madrid 28023, Spain
| | - María Cruz
- Reproductive Medicine Department, Instituto Valenciano de Infertilidad IVI Madrid, Avenida del Talgo 68-70, Aravaca, Madrid 28023, Spain
| | - Francisco J Ruiz
- Reproductive Medicine Department, Instituto Valenciano de Infertilidad IVI Madrid, Avenida del Talgo 68-70, Aravaca, Madrid 28023, Spain
| | - Juan A García-Velasco
- Reproductive Medicine Department, Instituto Valenciano de Infertilidad IVI Madrid, Avenida del Talgo 68-70, Aravaca, Madrid 28023, Spain
- Nursing, Gynecology and Obstetrics, Pediatrics and Psychiatry Department, Faculty of Health Sciences, Rey Juan Carlos University, Avda. Atenas s/n, Alcorcón, Madrid 28922, Spain
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Humaidan P, Polyzos NP, Alsbjerg B, Erb K, Mikkelsen AL, Elbaek HO, Papanikolaou EG, Andersen CY. GnRHa trigger and individualized luteal phase hCG support according to ovarian response to stimulation: two prospective randomized controlled multi-centre studies in IVF patients. Hum Reprod 2013; 28:2511-21. [DOI: 10.1093/humrep/det249] [Citation(s) in RCA: 155] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Humaidan P, Van Vaerenbergh I, Bourgain C, Alsbjerg B, Blockeel C, Schuit F, Van Lommel L, Devroey P, Fatemi H. Endometrial gene expression in the early luteal phase is impacted by mode of triggering final oocyte maturation in recFSH stimulated and GnRH antagonist co-treated IVF cycles. Hum Reprod 2012; 27:3259-72. [PMID: 22930004 DOI: 10.1093/humrep/des279] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION Do differences in endometrial gene expression exist after ovarian stimulation with four different regimens of triggering final oocyte maturation and luteal phase support in the same patient? SUMMARY ANSWER Significant differences in the expression of genes involved in receptivity and early implantation were seen between the four protocols. WHAT IS KNOWN ALREADY GnRH agonist triggering is an alternative to hCG triggering in GnRH antagonist co-treated cycles, resulting in an elimination of early ovarian hyperstimulation syndrome. Whereas previous studies have revealed a low ongoing clinical pregnancy rate after GnRH agonist trigger due to a high early pregnancy loss rate, despite supplementation with the standard luteal phase support, more recent studies, employing a 'modified' luteal phase support including a bolus of 1500 IU hCG on the day of oocyte aspiration, have reported ongoing pregnancy rates similar to those seen after hCG triggering. STUDY DESIGN, SIZE DURATION A prospective randomized study was performed in four oocyte donors recruited from an oocyte donation program during the period 2010-2011. PARTICIPANTS, MATERIALS, SETTING, METHODS Four oocyte donors in a university IVF center each prospectively underwent four consecutive stimulation protocols, with different modes of triggering final oocyte maturation and a different luteal phase support, followed by endometrial biopsy on Day 5 after oocyte retrieval. The following protocols were used: (A) 10 000 IU hCG and standard luteal phase support, (B) GnRH agonist (triptorelin 0.2 mg), followed by 1500 IU hCG 35 h after triggering final oocyte maturation, and standard luteal phase support, (C) GnRH agonist (triptorelin 0.2 mg) and standard luteal phase support and (D) GnRH agonist (triptorelin 0.2 mg) without luteal phase support. Microarray data analysis was performed with GeneSpring GX 11.5 (RMA algorithm). Pathway and network analysis was performed with the gene ontology software Ingenuity Pathways Analysis (Ingenuity® Systems, www.ingenuity.com, Redwood City, CA, USA). Samples were grouped and background intensity values were removed (cutoff at the lowest 20th percentile). A one-way ANOVA test (P< 0.05) was performed with Benjamini-Hochberg multiple testing correction. MAIN RESULTS Significant differences were seen in endometrial gene expression, related to the type of ovulation trigger and luteal phase support. However, the endometrial gene expression after the GnRH agonist trigger and a modified luteal phase support (B) was similar to the pattern seen after the hCG trigger (A). LIMITATIONS, REASONS FOR CAUTION The study was performed in four oocyte donors only; however, it is a strength of the study that the same donor underwent four consecutive stimulation protocols within 1 year to avoid inter-individual variations. WIDER IMPLICATIONS OF THE FINDINGS These endometrial gene-expression findings support the clinical reports of a non-significant difference in live birth rates between the GnRH agonist trigger and the hCG trigger, when the GnRH agonist trigger is followed by a bolus of 1500 IU hCG at 35 h post trigger in addition to the standard luteal phase support. STUDY FUNDING/ COMPETING INTERESTS This study was supported by an un-restricted research grant by MSD Belgium. TRIAL REGISTRATION NUMBER EudraCT number 2009-009429-26, protocol number 997 (P06034).
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Affiliation(s)
- P Humaidan
- The Fertility Clinic, Department D, Odense University Hospital, OHU, Entrance 55, Odense C 5000, Denmark.
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Chen SL, Ye DS, Chen X, Yang XH, Zheng HY, Tang Y, He YX, Guo W. Circulating luteinizing hormone level after triggering oocyte maturation with GnRH agonist may predict oocyte yield in flexible GnRH antagonist protocol. Hum Reprod 2012; 27:1351-6. [PMID: 22419746 DOI: 10.1093/humrep/des049] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The use of gonadotrophin-releasing hormone (GnRH) agonist for triggering final oocyte maturation and ovulation can reduce ovarian hyperstimulation syndrome (OHSS) in high-risk patients. LH levels post-trigger with GnRH agonist might be correlated with oocyte yield and maturity. Our aim was to evaluate the relationship between serum LH level at 12-h post-trigger and oocyte yield, maturity and fertilization rate in patients at high risk of OHSS and therefore who were treated with a flexible GnRH antagonist protocol in which final oocyte maturation was triggered with GnRH agonist. METHODS In a prospective cohort study, 91 patients at high risk of OHSS were treated with a flexible GnRH antagonist protocol and divided into six groups according to their serum LH levels at 12-h after GnRH agonist administration: ≤15.0, 15.1-30.0, 30.1-45.0, 45.1-60.0, 60.1-75.0 and >75.0 IU/l. The oocyte yield, maturity, fertilization rate and clinical outcomes for each LH interval were analyzed. RESULTS There was a statistically significant reduction in oocyte yield with a concentration of serum LH ≤15.0 IU/l (P < 0.05), whereas no statistically significant differences in the oocyte maturity and fertilization rate among the six groups (P > 0.05) were seen. Only 5 out of 91 patients (5.5%) had a serum LH ≤15.0 IU/l at 12-h post-trigger with GnRH agonist. In addition, no statistically significant difference was seen regarding high-quality embryos, implantation rate, clinical pregnancy rate and early miscarriage between patients with LH ≤15.0 IU/l and >15.0 IU/l (P > 0.05). CONCLUSIONS Serum LH level at 12-h post-trigger with GnRHa <15.0 IU/l is associated with a dramatically lower oocyte yield but not with the oocyte maturity and fertilization rate. Serum LH levels post-trigger with GnRH agonist do not affect clinical outcomes.
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Affiliation(s)
- Shi-Ling Chen
- Center for Reproductive Medicine, Department of Gynecology and Obstetrics, Nanfang Hospital, Southern Medical University, Guangzhou 510515, People's Republic of China.
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The luteal phase after GnRH-agonist triggering of ovulation: present and future perspectives. Reprod Biomed Online 2012; 24:134-41. [DOI: 10.1016/j.rbmo.2011.11.001] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2011] [Revised: 10/03/2011] [Accepted: 11/02/2011] [Indexed: 10/15/2022]
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Humaidan P, Westergaard LG, Mikkelsen AL, Fukuda M, Yding Andersen C. Levels of the epidermal growth factor-like peptide amphiregulin in follicular fluid reflect the mode of triggering ovulation: a comparison between gonadotrophin-releasing hormone agonist and urinary human chorionic gonadotrophin. Fertil Steril 2011; 95:2034-8. [DOI: 10.1016/j.fertnstert.2011.02.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2010] [Revised: 01/26/2011] [Accepted: 02/07/2011] [Indexed: 02/02/2023]
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Lamb JD, Shen S, McCulloch C, Jalalian L, Cedars MI, Rosen MP. Follicle-stimulating hormone administered at the time of human chorionic gonadotropin trigger improves oocyte developmental competence in in vitro fertilization cycles: a randomized, double-blind, placebo-controlled trial. Fertil Steril 2011; 95:1655-60. [DOI: 10.1016/j.fertnstert.2011.01.019] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Revised: 12/07/2010] [Accepted: 01/06/2011] [Indexed: 10/18/2022]
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Kol S, Humaidan P. LH (as HCG) and FSH surges for final oocyte maturation: sometimes it takes two to tango? Reprod Biomed Online 2010; 21:590-2. [DOI: 10.1016/j.rbmo.2010.06.031] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2010] [Revised: 05/25/2010] [Accepted: 06/16/2010] [Indexed: 11/16/2022]
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Humaidan P, Papanikolaou E, Tarlatzis B. GnRHa to trigger final oocyte maturation: a time to reconsider. Hum Reprod 2009; 24:2389-94. [DOI: 10.1093/humrep/dep246] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Grøndahl ML, Borup R, Lee YB, Myrhøj V, Meinertz H, Sørensen S. Differences in gene expression of granulosa cells from women undergoing controlled ovarian hyperstimulation with either recombinant follicle-stimulating hormone or highly purified human menopausal gonadotropin. Fertil Steril 2009; 91:1820-30. [DOI: 10.1016/j.fertnstert.2008.02.137] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2007] [Revised: 02/19/2008] [Accepted: 02/19/2008] [Indexed: 10/22/2022]
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Humaidan P, Ejdrup Bredkjaer H, Westergaard LG, Yding Andersen C. 1,500 IU human chorionic gonadotropin administered at oocyte retrieval rescues the luteal phase when gonadotropin-releasing hormone agonist is used for ovulation induction: a prospective, randomized, controlled study. Fertil Steril 2009; 93:847-54. [PMID: 19200959 DOI: 10.1016/j.fertnstert.2008.12.042] [Citation(s) in RCA: 158] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2008] [Revised: 11/06/2008] [Accepted: 12/10/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To prospectively assess the reproductive outcome with a small bolus of hCG administered on the day of oocyte retrieval after ovulation induction with a GnRH agonist (GnRHa). DESIGN Prospective, randomized trial. SETTING Three hospital-based IVF clinics. PATIENT(S) Three hundred five IVF/intracytoplasmic sperm injection patients after a GnRH antagonist protocol. INTERVENTION(S) Ovulation induction was performed with either 10,000 IU hCG or 0.5 mg GnRHa (buserelin) supplemented with 1,500 IU hCG on the day of oocyte retrieval. MAIN OUTCOME MEASURE(S) Reproductive outcome in the two groups. RESULT(S) No significant differences were seen regarding positive hCG/ET rate (48% and 48%), ongoing pregnancy rate (26% and 33%), delivery rate (24% and 31%), and rate of early pregnancy loss (21% and 17%) between the GnRHa and 10,000 IU hCG groups, respectively. CONCLUSION(S) A small bolus of hCG in the GnRHa group secured the luteal phase, resulting in a comparable reproductive outcome in the two groups. However, a nonsignificant difference of 7% in delivery rates justifies further studies to refine the use of GnRHa for ovulation induction.
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Affiliation(s)
- Peter Humaidan
- The Fertility Clinic, Skive Regional Hospital, Resenvej 25, 7800 Skive, Denmark.
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Luteal phase rescue in high-risk OHSS patients by GnRHa triggering in combination with low-dose HCG: a pilot study. Reprod Biomed Online 2009; 18:630-4. [DOI: 10.1016/s1472-6483(10)60006-5] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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45
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Letterie GS, Lee JS, Padmanabhan V. Assessment of ovarian reserve by using the follicle-stimulating hormone isoform distribution pattern to predict the outcome of in vitro fertilization. Fertil Steril 2006; 86:1547-9. [PMID: 16999956 DOI: 10.1016/j.fertnstert.2006.03.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2005] [Revised: 03/29/2006] [Accepted: 03/29/2006] [Indexed: 11/15/2022]
Abstract
Changes in FSH isoforms occur at temporally specific times during the menstrual cycle and reproductive lifespan. Changes in ratio in FSH isoforms may provide a sensitive test of ovarian reserve before IVF.
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Affiliation(s)
- Gerard S Letterie
- Northwest Center for Reproductive Sciences, Seattle, Washington 98119, USA..
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Humaidan P, Bredkjaer HE, Bungum L, Bungum M, Grøndahl ML, Westergaard L, Andersen CY. GnRH agonist (buserelin) or hCG for ovulation induction in GnRH antagonist IVF/ICSI cycles: a prospective randomized study. Hum Reprod 2005; 20:1213-20. [PMID: 15760966 DOI: 10.1093/humrep/deh765] [Citation(s) in RCA: 364] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND We aimed to determine the efficacy of ovarian hyperstimulation protocols employing a GnRH antagonist to prevent a premature LH rise allowing final oocyte maturation and ovulation to be induced by a single bolus of either a GnRH agonist or hCG. METHODS A total of 122 normogonadotrophic patients following a flexible antagonist protocol was stimulated with recombinant human FSH and prospectively randomized (sealed envelopes) to ovulation induction with a single bolus of either 0.5 mg buserelin s.c. (n = 55) or 10,000 IU of hCG (n = 67). A maximum of two embryos was transferred. Luteal support consisted of micronized progesterone vaginally, 90 mg a day, and estradiol, 4 mg a day per os. RESULTS Ovulation was induced with GnRH agonist in 55 patients and hCG in 67 patients. Significantly more metaphase II (MII) oocytes were retrieved in the GnRH agonist group (P < 0.02). Significantly higher levels of LH and FSH (P < 0.001) and significantly lower levels of progesterone and estradiol (P < 0.001) were seen in the GnRH agonist group during the luteal phase. The implantation rate, 33/97 versus 3/89 (P < 0.001), clinical pregnancy rate, 36 versus 6% (P = 0.002), and rate of early pregnancy loss, 4% versus 79% (P = 0.005), were significantly in favour of hCG. CONCLUSIONS Ovulation induction with a GnRH agonist resulted in significantly more MII oocytes. However, a significantly lower implantation rate and clinical pregnancy rate in addition to a significantly higher rate of early pregnancy loss was seen in the GnRH agonist group, most probably due to a luteal phase deficiency.
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Affiliation(s)
- P Humaidan
- The Fertility Clinic, Viborg Hospital (Skive), Denmark.
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47
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Wolfenson C, Groisman J, Couto AS, Hedenfalk M, Cortvrindt RG, Smitz JE, Jespersen S. Batch-to-batch consistency of human-derived gonadotrophin preparations compared with recombinant preparations. Reprod Biomed Online 2005; 10:442-54. [PMID: 15901450 DOI: 10.1016/s1472-6483(10)60819-x] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Different gonadotrophin preparations derived from human urine or manufactured by recombinant technology are currently used in clinical practice for the treatment of infertility. It has been widely assumed that gonadotrophin products manufactured by recombinant technology have better batch-to-batch consistency compared with human-derived preparations and that this potentially will be shown to provide a more constant clinical response, but there is little evidence for either statement. This study compared the batch-to-batch consistency between urinary-derived and recombinant manufactured gonadotrophin preparations using standard analytical techniques, as well as a novel in-vitro follicle bioassay to evaluate the consistency of the biological response at the target organ. Oligosaccharide isoform profiling, immunoassay testing, size exclusion chromatography analysis and in-vitro bioassay testing of urinary derived gonadotrophin preparations (MENOPUR and BRAVELLE) confirm that these products display a high degree of batch-to-batch consistency, similar to recombinant FSH (GONAL-f) either filled by mass or bioassay. The data also suggest that the batch-to-batch variation is independent of the manufacturing procedure (filled-by-bioassay or filled-by-mass) for the recombinant preparation (Gonal-f), but that the total FSH bioactivity delivered from a single dose preparation after reconstitution differs between the two manufacturing procedures.
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Ulloa-Aguirre A, Timossi C, Barrios-de-Tomasi J, Maldonado A, Nayudu P. Impact of carbohydrate heterogeneity in function of follicle-stimulating hormone: studies derived from in vitro and in vivo models. Biol Reprod 2003; 69:379-89. [PMID: 12700183 DOI: 10.1095/biolreprod.103.016915] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Carbohydrates attached to the protein core of glycoprotein hormones influence a number of intracellular and extracellular processes. As with other members of the glycoprotein hormone family, FSH is produced and released as an array of isoforms that differ from each other in the structure of their oligosaccharide attachments. In this review, we discuss how carbohydrate heterogeneity can impact on FSH action in different in vitro and in vivo systems. We present evidence for diverse effects of distinct charge isoforms at the target cell level, including differential and unique effects on various end responses, and discuss how the use of multiple cell-type assays has allowed identification of some specific effects of FSH isoforms on different cell populations and follicle compartments as well as oocyte maturation. Finally, we discuss recent information on the ability of naturally occurring and laboratory manufactured FSH isoforms to evoke particular effects on granulosa cell function and ovarian follicular maturation in vivo. Such studies have provided evidence that the type(s) of FSH signal delivered may in fact regulate distinct biological outcomes irrespective or in addition to outcomes dictated solely by clearance rate differences.
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Affiliation(s)
- Alfredo Ulloa-Aguirre
- Research Unit in Reproductive Medicine, Hospital de Ginecobstetricia Luis Castelazo Ayala, IMSS, México DF.
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Balasch J, Peñarrubia J, Fábregues F, Vidal E, Casamitjana R, Manau D, Carmona F, Creus M, Vanrell JA. Ovarian responses to recombinant FSH or HMG in normogonadotrophic women following pituitary desensitization by a depot GnRH agonist for assisted reproduction. Reprod Biomed Online 2003; 7:35-42. [PMID: 12930572 DOI: 10.1016/s1472-6483(10)61726-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
At present, there is considerable debate about the utility of supplemental LH in assisted reproduction treatment. In order to explore this, the present authors used a depot gonadotrophin-releasing hormone agonist (GnRHa) protocol combined with recombinant human FSH (rhFSH) or human menopausal gonadotrophin (HMG) in patients undergoing intracytoplasmic sperm injection (ICSI). The response to either rhFSH (75 IU FSH/ampoule; group rhFSH, 25 patients) or HMG (75 IU FSH and 75 IU LH/ampoule; group HMG, 25 patients) was compared in normo-ovulatory women suppressed with a depot triptorelin injection and candidates for ICSI. A fixed regimen of 150 IU rhFSH or HMG was administered in the first 14 days of treatment. Treatment was monitored with transvaginal pelvic ultrasonographic scans and serum measurement of FSH, LH, oestradiol, androstenedione, testosterone, progesterone, inhibin A, inhibin B and human chorionic gonadotrophin (HCG) at 2-day intervals. Although oestradiol serum concentrations on the day of HCG injection were similar, both the duration of treatment and the per cycle gonadotrophin dose were lower in group HMG. In the initial 16 days of gonadotrophin treatment, the area under the curve (AUC) of LH, oestradiol, androstenedione and inhibin B were higher in group HMG; no differences were seen for the remaining hormones measured, including the inhibin B:inhibin A ratio. The dynamics of ovarian follicle development during gonadotrophin treatment were similar in both study groups, but there were more leading follicles (>17 mm in diameter) on the day of HCG injection in the rhFSH group. The number of oocytes, mature oocytes and good quality zygotes and embryos obtained were significantly increased in the rhFSH group. It is concluded that in IVF patients undergoing pituitary desensitization with a depot agonist preparation, supplemental LH may be required in terms of treatment duration and gonadotrophin consumption. However, both oocyte, embryo yield and quality were significantly higher with the use of rhFSH.
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Affiliation(s)
- Juan Balasch
- Institut Clínic of Gynecology, Obstetrics and Neonatology, and Hormonal Laboratory, Faculty of Medicine, University of Barcelona, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain.
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50
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Nayudu PL, Vitt UA, Barrios De Tomasi J, Pancharatna K, Ulloa-Aguirre A. Intact follicle culture: what it can tell us about the roles of FSH glycoforms during follicle development. Reprod Biomed Online 2002; 5:240-53. [PMID: 12470521 DOI: 10.1016/s1472-6483(10)61827-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
An important limiting factor in assisted reproduction treatment success rates is oocyte quality. In spite of improved results through several important innovations, the pregnancy rate per collected oocyte remains far too low. In order to improve this situation, it is necessary to learn more about fundamental factors modulating follicular development patterns. FSH is known to be the driving force for follicle development, but it is not yet understood how its multifarious functions are controlled and modulated. Evidence is accumulating that FSH glycoforms may be the key to this mystery. Intact follicle culture is a useful tool for the clarification of the actions of the different isoforms because the follicle unit is maintained and allowed to develop through several critical stages. Additionally important is the availability of the oocyte for functional evaluation. Because of these features, relationships can be uncovered that are not revealed with single cell test systems. The results so far obtained with this system suggest that follicle development pattern and oocyte quality is strongly influenced by FSH glycoform range, and that the requirements of the follicle may shift during progress through different stages of development. More studies are required, but these findings already suggest that the physiological shifts of circulating FSH glycoforms may indeed be important, and that attention should be paid to the glycoform distribution of exogenously applied FSH.
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Affiliation(s)
- Penelope L Nayudu
- Gamete Biology Laboratory, Department of Reproductive Biology, German Primate Centre, Kellnerweg 4, D-37077 Göttingen, Germany.
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