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Nasatzky M, Belicha Y, Fainaru O. Clinical parameters that predict a premature LH rise in patients undergoing ovarian stimulation for IVF. Gynecol Endocrinol 2024; 40:2365913. [PMID: 38946245 DOI: 10.1080/09513590.2024.2365913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 06/04/2024] [Indexed: 07/02/2024] Open
Abstract
Background: Normal reproductive function requires adequate regulation of follicle stimulating hormone (FSH) and luteinizing hormone (LH) secretion. During ovarian stimulation for in-vitro fertilization (IVF), some patients will demonstrate an early rise in LH despite being treated with a gonadotropin releasing-hormone (GnRH) antagonist, sometimes necessitating cycle cancellation. Previous studies have demonstrated a possible link between a premature LH rise with ovarian response to gonadotropins. We sought to determine what clinical parameters can predict this premature LH rise and their relative contribution. Methods: A retrospective study of 382 patients who underwent IVF treatment at Rambam Medical Center. The patients were stratified into age groups. A model predicting premature LH rise based on clinical and demographic parameters was developed using both multiple linear regression and a machine-learning-based algorithm. Results: LH rise was defined as the difference between pre-trigger and basal LH levels. The clinical parameters that significantly predicted an LH rise were patient age, BMI, LH levels at stimulation outset, LH levels on day of antagonist administration, and total number of stimulation days. Importantly, when analyzing the data of specific age groups, the model's prediction was strongest in young patients (age 25-30 years, R2 = 0.88, p < .001) and weakest in older patients (age > 41 years, R2 = 0.23, p = .003). Conclusions: Using both multiple linear regression and a machine-learning-based algorithm of patient data from IVF cycles, we were able to predict patients at risk for premature LH rise and/or LH surge. Utilizing this model may help prevent IVF cycle cancellation and better timing of ovulation triggering.
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Affiliation(s)
- Maya Nasatzky
- IVF Unit, Rambam Medical Center, Haifa, Israel
- Rappaport School of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Yonathan Belicha
- IVF Unit, Rambam Medical Center, Haifa, Israel
- Rappaport School of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Ofer Fainaru
- IVF Unit, Rambam Medical Center, Haifa, Israel
- Rappaport School of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
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Federica DG, De Rijdt S, Racca A, Drakopoulos P, Mackens S, Strypstein L, Tournaye H, De Vos M, Blockeel C. Impact of GnRH antagonist pretreatment on oocyte yield after ovarian stimulation: A retrospective analysis. PLoS One 2024; 19:e0308666. [PMID: 39374231 PMCID: PMC11458021 DOI: 10.1371/journal.pone.0308666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 07/27/2024] [Indexed: 10/09/2024] Open
Abstract
The study investigates whether a 3-day pretreatment course with a GnRH antagonist in the early follicular phase has an impact on the number of retrieved COCs in a GnRH antagonist stimulation protocol. This is a retrospective single center crossover study involving women who did not conceive after one GnRH antagonist stimulation cycle ("standard cycle") and proceeded with another GnRH antagonist stimulation cycle preceded by early administration of GnRH antagonist for 3 days ("pretreatment cycle") with fresh embryo transfer or frozen embryo transfer. 430 patients undergoing 860 cycles were included. The mean female age was 34.4 ± 4.8 years. Indications for fertility treatment included unexplained infertility (34.3%), male-factor infertility (33.3%), age (16.9%), PCOS (8.2%), tubal (4.7) and endometriosis (2.6%). All cycles were divided into two groups: group 1 (standard, 430 cycles) and group 2 (pretreatment, 430 cycles). The mean duration of stimulation was similar in both groups (10.3 vs 10.3 days, p = 0.28). The starting dose of gonadotropin (234.9 vs 196.8 IU, p<0.001), total amount of gonadotropin used (2419 vs 2020 IU, p<0.001), the total number of retrieved COCs (10 vs 7.8 p<0.001) and the number of mature oocytes (8 vs 5.8 p<0.001) were significantly higher in group 2 than in group 1. The Generalized estimating equation (GEE) regression analysis showed that the pretreatment strategy had a significant positive effect on the number of COCs (coefficient 2.4, p <0.001 after adjusting for known confounders (age, indication, stimulation dose, type, and duration of stimulation). In conclusion, A 3-day course of GnRH antagonist pretreatment increases the number of COCs obtained after ovarian stimulation.
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Affiliation(s)
- Di Guardo Federica
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Sylvie De Rijdt
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Annalisa Racca
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
- Centre of Reproductive Medicine, Instituto Bernabeu Venezia, Martellago, Venezia, Italy
| | - Panagiotis Drakopoulos
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
- Embryolab, IVF Unit, Thessaloniki, Greece
| | - Shari Mackens
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Laurence Strypstein
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Herman Tournaye
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Obstetrics, Gynecology, Perinatology and Reproduction, Institute of Professional Education, Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Michel De Vos
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Obstetrics, Gynecology, Perinatology and Reproduction, Institute of Professional Education, Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Christophe Blockeel
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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Wang Y, Xu J, Yin X, Fang Y, Li K. The comparision among euploidy of preimplantation blastocysts in different controlled ovary stimulation (COH) protocols. Arch Gynecol Obstet 2024; 310:1687-1695. [PMID: 38713294 DOI: 10.1007/s00404-024-07474-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 03/11/2024] [Indexed: 05/08/2024]
Abstract
PURPOSE To compare differences in euploidy rates for blastocysts in preimplantation genetic testing for aneuploidy (PGT-A) cycles after gonadotropin-releasing hormone agonist (GnRH-a) long and short protocols, GnRH-antagonist (GnRH-ant) protocol, progestin-primed ovarian stimulation and mild stimulation protocols, and other ovary stimulation protocols. METHODS This was a retrospective cohort study from the Assisted Reproductive Medicine Department of Shanghai First Maternity and Infant Hospital. A total of 1657 PGT-A cycles with intracytoplasmic sperm injection after different controlled ovary hyperstimulation protocols were analyzed, and a total of 3154 embryos were biopsied. Differences in euploidy rate per embryo biopsied, embryo euploidy rate per oocyte retrieved and cycle cancellation rate were compared. RESULTS For the PGT-A cycles, the euploidy rate per embryo biopsied was lower in the GnRH-ant protocol than in the GnRH-a long protocol (53.26 vs. 58.68%, respectively). Multiple linear regression showed that the GnRH-ant protocol was associated with a lower euploidy rate per embryo biopsied (β = -0.079, p = 0.011). The euploidy rate per embryo biopsied was not affected by total gonadotropin dosage, duration of stimulation and number of oocytes retrieved. The embryo euploidy rate per oocyte retrieved was similar in all protocols and was negatively correlated with the total number of oocytes retrieved (β = -0.003, p = 0.003). CONCLUSION Compared with the GnRH-a long protocol, the GnRH-ant protocol was associated with a lower euploidy rate per embryo biopsied. The total gonadotropin dosage, duration of stimulation and number of oocytes retrieved did not appear to significantly influence euploidy rates.
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Affiliation(s)
- Yu Wang
- School of Medicine, Shanghai First Maternity and Infant Hospital, Centre for Reproductive Medicine, Tongji University, #2699, Gaoke West Road, Shanghai, 200092, China
| | - Junting Xu
- School of Medicine, Shanghai First Maternity and Infant Hospital, Centre for Reproductive Medicine, Tongji University, #2699, Gaoke West Road, Shanghai, 200092, China
| | - Xiangjie Yin
- School of Medicine, Shanghai First Maternity and Infant Hospital, Centre for Reproductive Medicine, Tongji University, #2699, Gaoke West Road, Shanghai, 200092, China
| | - Yuan Fang
- School of Medicine, Shanghai First Maternity and Infant Hospital, Centre for Reproductive Medicine, Tongji University, #2699, Gaoke West Road, Shanghai, 200092, China
| | - Kunming Li
- School of Medicine, Shanghai First Maternity and Infant Hospital, Centre for Reproductive Medicine, Tongji University, #2699, Gaoke West Road, Shanghai, 200092, China.
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Xie Q, Jiang W, Wei Y, Ni D, Yan N, Yang Y, Zhao C, Shen R, Ling X. Increasing dominant follicular proportion was associated with adverse IVF/ICSI outcomes in low-prognosis women undergoing GnRH antagonist protocol: a retrospective cohort study. J Ovarian Res 2024; 17:179. [PMID: 39217358 PMCID: PMC11365273 DOI: 10.1186/s13048-024-01502-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Accepted: 08/19/2024] [Indexed: 09/04/2024] Open
Abstract
PURPOSE This study aimed to examine the correlation between different dominant follicle proportions (DFPs) and outcomes of in-vitro fertilization or intracytoplasmic sperm injection (IVF/ICSI) among patients classified under POSEIDON Groups 3 and 4, who underwent gonadotropin-releasing hormone antagonist (GnRH-ant) protocols. Additionally, it sought to determine the optimal DFP threshold for trigger timing. METHODS A retrospective analysis was performed on patients classified under POSEIDON Groups 3 (n = 593) and 4 (n = 563) who underwent GnRH-ant protocols for controlled ovarian hyperstimulation (COH) between 2016 and 2022. These patients were categorized into two groups based on their DFPs, defined as the ratio of ≥ 18-mm dominant follicles to ≥ 12-mm follicles on the trigger day (DFP ≤ 40% and DFP ≥ 40%). Statistical analyses, including restricted cubic spline (RCS) and multivariate logistic regression, were employed to assess the relationship between DFP and IVF/ICSI outcomes. RESULTS Demographic characteristics of patients were similar across groups. In POSEIDON Groups 3 and 4, DFP > 40 was associated with a significant decrease in the number (No.) of oocytes retrieved, cleaved embryos, and available embryos. Moreover, following the GnRH-ant cycle, the clinical pregnancy and live birth rates in fresh embryo transfer (ET) were notably reduced in the DFP > 40 group compared with the DFP ≤ 40 group, whereas no significant differences were observed in the pregnancy outcomes of the first frozen-thawed embryo transfer (FET) between the groups. In POSEIDON Group 3, the cumulative clinical pregnancy rate (CCPR) and cumulative live birth rate (CLRB) were significantly higher in the DFP ≤ 40 subgroup than in the DFP > 40 subgroup, with a notable decrease in CLRB observed with increasing DFP levels. However, in POSEIDON Group 4, no significant differences in CCPR and CLRB were found between the groups. Logistic regression analysis identified age and the No. of oocytes retrieved as pivotal factors influencing CLRB in Group 4. CONCLUSION For patients in POSEIDON Group 3, maintaining a DFP ≤ 40 mm is crucial to achieve optimal laboratory and pregnancy outcomes by avoiding delayed triggering. However, for patients in POSEIDON Group 4, age remains a critical factor influencing CLRB regardless of DFP, although a higher No. of oocytes retrieved and available embryos with DFP ≤ 40 is beneficial.
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Affiliation(s)
- Qijun Xie
- Department of Reproductive Medicine, Women's Hospital of Nanjing Medical University, Nanjing Women and Children's Healthcare Hospital, 123 Tianfeixiang, Mochou Road, Nanjing, 210004, Jiangsu, China
| | - Wei Jiang
- Department of Reproductive Medicine, Women's Hospital of Nanjing Medical University, Nanjing Women and Children's Healthcare Hospital, 123 Tianfeixiang, Mochou Road, Nanjing, 210004, Jiangsu, China
| | - Yi Wei
- Department of Reproductive Medicine, Women's Hospital of Nanjing Medical University, Nanjing Women and Children's Healthcare Hospital, 123 Tianfeixiang, Mochou Road, Nanjing, 210004, Jiangsu, China
| | - Danyu Ni
- Department of Reproductive Medicine, Women's Hospital of Nanjing Medical University, Nanjing Women and Children's Healthcare Hospital, 123 Tianfeixiang, Mochou Road, Nanjing, 210004, Jiangsu, China
| | - Nan Yan
- Department of Reproductive Medicine, Women's Hospital of Nanjing Medical University, Nanjing Women and Children's Healthcare Hospital, 123 Tianfeixiang, Mochou Road, Nanjing, 210004, Jiangsu, China
| | - Ye Yang
- Department of Reproductive Medicine, Women's Hospital of Nanjing Medical University, Nanjing Women and Children's Healthcare Hospital, 123 Tianfeixiang, Mochou Road, Nanjing, 210004, Jiangsu, China
| | - Chun Zhao
- Department of Reproductive Medicine, Women's Hospital of Nanjing Medical University, Nanjing Women and Children's Healthcare Hospital, 123 Tianfeixiang, Mochou Road, Nanjing, 210004, Jiangsu, China
| | - Rong Shen
- Department of Reproductive Medicine, Women's Hospital of Nanjing Medical University, Nanjing Women and Children's Healthcare Hospital, 123 Tianfeixiang, Mochou Road, Nanjing, 210004, Jiangsu, China.
- Department of Obstetrics and Gynecology, Nanjing Women and Children's Healthcare Hospital, Women's Hospital of Nanjing Medical University, 123 Tianfeixiang, Mochou Road, Nanjing, 210004, Jiangsu, China.
| | - Xiufeng Ling
- Department of Reproductive Medicine, Women's Hospital of Nanjing Medical University, Nanjing Women and Children's Healthcare Hospital, 123 Tianfeixiang, Mochou Road, Nanjing, 210004, Jiangsu, China.
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Liu C, Tian T, Lou Y, Li J, Liu P, Li R, Qiao J, Wang Y, Yang R. Live birth rate of gonadotropin-releasing hormone antagonist versus luteal phase gonadotropin-releasing hormone agonist protocol in IVF/ICSI: a systematic review and meta-analysis. Expert Rev Mol Med 2023; 26:e2. [PMID: 38095077 PMCID: PMC10941349 DOI: 10.1017/erm.2023.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 08/18/2023] [Accepted: 10/25/2023] [Indexed: 02/15/2024]
Abstract
In vitro fertilization (IVF) and embryo transfer and intracytoplasmic sperm injection (ICSI) have allowed millions of infertile couples to achieve pregnancy. As an essential part of IVF/ICSI enabling the retrieval of a high number of oocytes in one cycle, controlled ovarian stimulation (COS) treatment mainly composes of the standard long gonadotrophin-releasing hormone agonist (GnRH-a) protocol and the gonadotrophin-releasing hormone antagonist (GnRH-ant) protocol. However, the effectiveness of GnRH-ant protocol is still debated because of inconsistent conclusions and insufficient subgroup analyses. This systematic review and meta-analysis included a total of 52 studies, encompassing 5193 participants in the GnRH-ant group and 4757 in the GnRH-a group. The findings of this study revealed that the GnRH-ant protocol is comparable with the long GnRH-a protocol when considering live birth as the primary outcome, and it is a favourable protocol with evidence reducing the incidence of ovarian hyperstimulation syndrome in women undergoing IVF/ICSI, especially in women with polycystic ovary syndrome. Further research is needed to compare the subsequent cumulative live birth rate between the two protocols among the general and poor ovarian response patients since those patients have a lower clinical pregnancy rate, fewer oocytes retrieved or fewer high-grade embryos in the GnRH-ant protocol.
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Affiliation(s)
- Chenhong Liu
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
| | - Tian Tian
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
| | - Yanru Lou
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
| | - Jia Li
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
| | - Ping Liu
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
| | - Rong Li
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
| | - Jie Qiao
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
| | - Yuanyuan Wang
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
| | - Rui Yang
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
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Ciebiera M, Madueke-Laveaux OS, Feduniw S, Ulin M, Spaczyński R, Zgliczyńska M, Bączkowska M, Zarychta E, Łoziński T, Ali M, Al-Hendy A. GnRH agonists and antagonists in therapy of symptomatic uterine fibroids - current roles and future perspectives. Expert Opin Pharmacother 2023; 24:1799-1809. [PMID: 37602464 DOI: 10.1080/14656566.2023.2248890] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/12/2023] [Accepted: 08/14/2023] [Indexed: 08/22/2023]
Abstract
INTRODUCTION Uterine fibroids are the most common noncancerous tumors in women of childbearing age. This review was developed to evaluate the current role of gonadotropin-releasing hormone (GnRH) agonists and antagonists in the therapy of symptomatic uterine fibroids. AREAS COVERED There is a great need for alternative methods for surgical treatment of uterine fibroids. Hormonal therapy remains the first-line treatment option for most patients. GnRH analogs (agonists and antagonists) modulate the pulsatile release of GnRH. This review summarizes the available literature concerning pharmacologic principles underlying the mechanism of action of GnRH and its analogs, as well as individual therapeutic applications to which these drugs have been applied. EXPERT OPINION In many cases, it is possible to try to treat uterine fibroids pharmacologically. Both groups of GnRH analogs are used in therapy, agonists instead as a preparation for surgery, and antagonists as a drug for long-term use. It is essential to develop this path further and look for at least long-term-release systems or new methods of administering these drugs. It is also important from the patient's perspective to search for possible drugs that may have an additive effect of decreasing side effects when combined with GnRH analogs.
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Affiliation(s)
- Michał Ciebiera
- Second Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Warsaw, Poland
- Warsaw Institute of Women's Health, Warsaw, Poland
- Development and Research Center of Non-Invasive Therapies, Pro-Familia Hospital, Rzeszów, Poland
| | | | - Stepan Feduniw
- Department of Gynecology, University Hospital Zurich, Zurich, Switzerland
| | - Mara Ulin
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, Chicago, IL, USA
| | - Robert Spaczyński
- Obstetrics and Infertility Treatment Pastelova, Center for Gynecology, Poznan, Poland
| | - Magdalena Zgliczyńska
- Department of Obstetrics, Perinatology and Neonatology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Monika Bączkowska
- Second Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Elżbieta Zarychta
- Second Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Tomasz Łoziński
- Department of Obstetrics and Gynecology, Pro-Familia Hospital, Rzeszow, Poland
- Department of Gynecology and Obstetrics, College of Medical Sciences, Institute of Medical Sciences, University of Rzeszow, Rzeszow, Poland
| | - Mohamed Ali
- Department of Obstetrics and Gynecology, University of Chicago Medicine, Chicago, IL, USA
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago Medicine, Chicago, IL, USA
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Humaidan P, Haahr T. GnRHa trigger-the story of the ugly duckling. F S Rep 2023; 4:15-19. [PMID: 37223771 PMCID: PMC10201294 DOI: 10.1016/j.xfre.2023.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 12/07/2022] [Accepted: 02/22/2023] [Indexed: 03/03/2023] Open
Abstract
The objective of this invited review is to describe the introduction and development of the GnRH agonist (GnRHa) trigger protocol in modern in vitro fertilization, focusing on ovarian hyperstimulation syndrome (OHSS) prevention and, equally important on the role of GnRHa trigger as an opener of the luteal phase "black box." The GnRHa trigger and freezing of all embryos is the ultimate weapon against OHSS in the OHSS-risk patient. In the non OHSS-risk patient, GnRHa trigger followed by a modified luteal phase support with lutein hormone activity and subsequent fresh embryo transfer results in excellent reproductive outcomes. Thus, the GnRHa trigger has paved the way for a virtually OHSS-free clinic, and equally important is the fact that the early lessons learned from studying the GnRHa trigger opened the "black box" of the luteal phase enabling improved reproductive outcomes in both fresh and frozen embryo transfer cycles.
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Affiliation(s)
- Peter Humaidan
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Fertility Clinic Skive, Skive Regional Hospital, Skive, Denmark
| | - Thor Haahr
- Fertility Clinic Skive, Skive Regional Hospital, Skive, Denmark
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
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8
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Venetis CA, Storr A, Chua SJ, Mol BW, Longobardi S, Yin X, D’Hooghe T. What is the optimal GnRH antagonist protocol for ovarian stimulation during ART treatment? A systematic review and network meta-analysis. Hum Reprod Update 2023; 29:307-326. [PMID: 36594696 PMCID: PMC10152179 DOI: 10.1093/humupd/dmac040] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/09/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Several GnRH antagonist protocols are currently used during COS in the context of ART treatments; however, questions remain regarding whether these protocols are comparable in terms of efficacy and safety. OBJECTIVE AND RATIONALE A systematic review followed by a pairwise and network meta-analyses were performed. The systematic review and pairwise meta-analysis of direct comparative data according to the PRISMA guidelines evaluated the effectiveness of different GnRH antagonist protocols (fixed Day 5/6 versus flexible, ganirelix versus cetrorelix, with or without hormonal pretreatment) on the probability of live birth and ongoing pregnancy after COS during ART treatment. A frequentist network meta-analysis combining direct and indirect comparisons (using the long GnRH agonist protocol as the comparator) was also performed to enhance the precision of the estimates. SEARCH METHODS The systematic literature search was performed using Embase (Ovid), MEDLINE (Ovid), Cochrane Central Register of Trials (CENTRAL), SCOPUS and Web of Science (WOS), from inception until 23 November 2021. The search terms comprised three different MeSH terms that should be present in the identified studies: GnRH antagonist; assisted reproduction treatment; randomized controlled trial (RCT). Only studies published in English were included. OUTCOMES The search strategy resulted in 6738 individual publications, of which 102 were included in the systematic review (corresponding to 75 unique studies) and 73 were included in the meta-analysis. Most studies were of low quality. One study compared a flexible protocol with a fixed Day 5 protocol and the remaining RCTs with a fixed Day 6 protocol. There was a lack of data regarding live birth when comparing the flexible and fixed GnRH antagonist protocols or cetrorelix and ganirelix. No significant difference in live birth rate was observed between the different pretreatment regimens versus no pretreatment or between the different pretreatment protocols. A flexible GnRH antagonist protocol resulted in a significantly lower OPR compared with a fixed Day 5/6 protocol (relative risk (RR) 0.76, 95% CI 0.62 to 0.94, I2 = 0%; 6 RCTs; n = 907 participants; low certainty evidence). There were insufficient data for a comparison of cetrorelix and ganirelix for OPR. OCP pretreatment was associated with a lower OPR compared with no pretreatment intervention (RR 0.79, 95% CI 0.69 to 0.92; I2 = 0%; 5 RCTs, n = 1318 participants; low certainty evidence). Furthermore, in the network meta-analysis, a fixed protocol with OCP resulted in a significantly lower OPR than a fixed protocol with no pretreatment (RR 0.84, 95% CI 0.71 to 0.99; moderate quality evidence). The surface under the cumulative ranking (SUCRA) scores suggested that the fixed protocol with no pretreatment is the antagonist protocol most likely (84%) to result in the highest OPR. There was insufficient evidence of a difference between fixed/flexible or OCP pretreatment/no pretreatment interventions regarding other outcomes, such as ovarian hyperstimulation syndrome and miscarriage rates. WIDER IMPLICATIONS Available evidence, mostly of low quality and certainty, suggests that different antagonist protocols should not be considered as equivalent for clinical decision-making. More trials are required to assess the comparative effectiveness of ganirelix versus cetrorelix, the effect of different pretreatment interventions (e.g. progestins or oestradiol) or the effect of different criteria for initiation of the antagonist in the flexible protocol. Furthermore, more studies are required examining the optimal GnRH antagonist protocol in women with high or low response to ovarian stimulation.
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Affiliation(s)
- C A Venetis
- University of New South Wales, Faculty of Medicine & Health, Centre for Big Data Research in Health & Discipline of Obstetrics and Gynaecology, Sydney, Australia
- IVFAustralia, Alexandria, NSW, Australia
| | - A Storr
- Flinders Fertility, Adelaide, SA, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - S J Chua
- Austin Health, Heidelberg, Australia
| | - B W Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
| | - S Longobardi
- Global Clinical Development, Merck Serono S.p.A, Rome, Italy, an affiliate of Merck KGaA
| | - X Yin
- EMD Serono Inc., R&D Global Biostatistics, Epidemiology & Medical Writing, Billerica, MA, USA, an affiliate of Merck KGaA
| | - T D’Hooghe
- Merck Healthcare KGaA, Darmstadt, Germany
- Department of Development and Regeneration, Laboratory of Endometrium, Endometriosis & Reproductive Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University Medical School, New Haven, CT, USA
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9
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Su H, Lai Y, Li J, Liao T, Ji L, Hu X, Qian K. Increasing dominant follicular proportion negatively associated with good clinical outcomes in normal ovarian responders using the depot GnRH agonist protocol: a large-sample retrospective analysis. J Ovarian Res 2022; 15:44. [PMID: 35418089 PMCID: PMC9006398 DOI: 10.1186/s13048-022-00973-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 03/26/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Currently, there is no universal criteria for the trigger time of controlled ovarian hyperstimulation (COH), especially with the emerging depot GnRH agonist protocol. It is challenging to explore an indicator that is representative of target follicle cohort development as an alternative to the conventional approach of determining the trigger time based on a few leading follicles. METHODS This was a large-sample retrospective analysis. Between January 2016 and January 2020, 1,925 young normal ovarian responders who underwent their first in vitro fertilisation (IVF)/intracytoplasmic sperm injection (ICSI) cycle using the depot GnRH agonist protocol were included. They were divided into three groups based on the dominant follicular proportion (DFP, defined as the ratio of ≥ 18 mm dominant follicles/ ≥ 14 mm large follicles on the human chorionic gonadotropin (HCG) day; Group A: < 30%; Group B: 30%-60%; and Group C: ≥ 60%). The binary logistic regression and multivariate linear regression were used to assess whether the DFP was associated with clinical pregnancy, the number of frozen blastocysts, the blastocyst formation rate, and the low number of frozen blastocysts. RESULTS The logistic regression analysis showed that compared with Group A, the odds ratio (OR) for clinical pregnancy was 1.345 in Group B (P = 0.023), and there was no statistical difference between Group C and Group A (P = 0.216). The multivariate linear regression analysis showed that DFP was negatively associated with the number of frozen blastocysts (β ± SE: Group B vs. Group A = - 0.319 ± 0.115, P = 0.006; Group C vs. Group A = - 0.432 ± 0.154, P = 0.005) as well as the blastocyst formation rate (β ± SE: Group B vs. Group A = - 0.035 ± 0.016, P = 0.031; Group C vs. Group A = - 0.039 ± 0.021, P = 0.067). Furthermore, the OR for the low number of frozen blastocysts was 1.312 in Group B (P = 0.039) and 1.417 in Group C (P = 0.041) compared to Group A. CONCLUSIONS For young normal ovarian responders using the depot GnRH agonist protocol, increasing DFP might reduce the developmental potential of oocytes and reduce the number of available blastocysts, and this might result in a lower cumulative pregnancy rate. However, further confirmation using strict prospective randomised controlled studies is required.
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Affiliation(s)
- Houming Su
- grid.33199.310000 0004 0368 7223Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Youhua Lai
- grid.33199.310000 0004 0368 7223Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jie Li
- grid.33199.310000 0004 0368 7223Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tingting Liao
- grid.33199.310000 0004 0368 7223Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Licheng Ji
- grid.33199.310000 0004 0368 7223Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xinyao Hu
- grid.33199.310000 0004 0368 7223Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kun Qian
- grid.33199.310000 0004 0368 7223Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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10
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Han EJ, Lyu SW, Kwak IP, Kwon H, Choi DH, Kim JY, Park HM, Kim JW, Chang EM, Lee HJ, Kim MK, Lee HN, Kim JY, Park SL, Lee WS. Efficacy and safety of newly developed ganirelix acetate in infertile women for assisted reproductive technology: a prospective, randomised, controlled study. J OBSTET GYNAECOL 2022; 42:2197-2202. [PMID: 35254199 DOI: 10.1080/01443615.2022.2036955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This study aimed to investigate the efficacy of Ganilever pre-filled syringe (PFS), a newly developed ganirelix acetate, for the inhibition of premature luteinising hormone (LH) surge in in vitro fertilisation (IVF). A prospective randomised controlled study was conducted (NCT03051087). A total of 236 women (Ganilever group: 114, Orgalutran group: 122) were finally analysed. The patients with LH of >10 mIU/mL on the day of human chorionic gonadotropin (hCG) injection were 0 (0.0%) and 3 (2.5%) in the Ganilever and Orgalutran groups, respectively (p= .25). The number of retrieved oocytes from two groups did not show any significant difference (12.0 ± 6.4 vs. 11.8 ± 6.3, p= .73). Furthermore, the two groups did not show significant differences in the number of good-quality oocytes and embryo, and the rate of fertilisation. Similar safety profiles were also observed. In conclusion, Ganilever PFS showed comparable IVF outcomes and safety profile in IVF, as compared to the Orgalutran. Impact StatementWhat is already known on this subject? Premature LH surge during controlled ovarian stimulation results in the induction of luteinisation of the immature follicles. Thus, gonadotrophin-releasing hormone (GnRH) antagonist protocol was suggested as an option for suppression of premature LH surge. Currently, one of GnRH antagonists being widely used is ganirelix acetate (Orgalutran®; Organon, Oss, The Netherlands). Ganilever pre-filled syringe (PFS) is a newly developed GnRH antagonist containing ganirelix acetate as an active ingredient.What do the results of this study add? Our study demonstrated that Ganilever PFS showed comparable IVF outcomes and patient safety profile in infertile women undergoing in IVF-ET, as compared to the Orgalutran.What are the implications of these findings for clinical practice and/or further research? The results of our study will provide another available GnRH antagonist to be used in patients with IVF.
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Affiliation(s)
- E Jung Han
- Department of Obstetrics and Gynecology, Fertility Center of CHA Gangnam Medical Center, CHA University School of Medicine, Seoul, South Korea
| | - Sang Woo Lyu
- Department of Obstetrics and Gynecology, Fertility Center of CHA Gangnam Medical Center, CHA University School of Medicine, Seoul, South Korea
| | - In Pyung Kwak
- Department of Obstetrics and Gynecology, Fertility Center of CHA Gangnam Medical Center, CHA University School of Medicine, Seoul, South Korea
| | - Hwang Kwon
- Department of Obstetrics and Gynecology, Fertility Center of CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, South Korea
| | - Dong Hee Choi
- Department of Obstetrics and Gynecology, Fertility Center of CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, South Korea
| | - Jin Young Kim
- Department of Obstetrics and Gynecology, Fertility Center of CHA Gangnam Medical Center, CHA University School of Medicine, Seoul, South Korea
| | - Han Moie Park
- Department of Obstetrics and Gynecology, Fertility Center of CHA Gangnam Medical Center, CHA University School of Medicine, Seoul, South Korea
| | - Ji Won Kim
- Department of Obstetrics and Gynecology, Fertility Center of CHA Gangnam Medical Center, CHA University School of Medicine, Seoul, South Korea
| | - Eun Mi Chang
- Department of Obstetrics and Gynecology, Fertility Center of CHA Gangnam Medical Center, CHA University School of Medicine, Seoul, South Korea
| | - Hee Jun Lee
- Department of Obstetrics and Gynecology, Fertility Center of CHA Gangnam Medical Center, CHA University School of Medicine, Seoul, South Korea
| | - Min Kyung Kim
- Department of Obstetrics and Gynecology, Fertility Center of CHA Gangnam Medical Center, CHA University School of Medicine, Seoul, South Korea
| | - Hye Nam Lee
- Department of Obstetrics and Gynecology, Fertility Center of CHA Gangnam Medical Center, CHA University School of Medicine, Seoul, South Korea
| | - Jeong Yun Kim
- Clinical Development Department, LG Chem Ltd., Seoul, South Korea
| | - So La Park
- Clinical Development Department, LG Chem Ltd., Seoul, South Korea
| | - Woo Sik Lee
- Department of Obstetrics and Gynecology, Fertility Center of CHA Gangnam Medical Center, CHA University School of Medicine, Seoul, South Korea
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11
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Correlation of LH level and steroid concentrations in GnRH antagonist protocol: A sub-analysis of Ganirelix phase III study of China. J Gynecol Obstet Hum Reprod 2022; 51:102363. [DOI: 10.1016/j.jogoh.2022.102363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 01/11/2022] [Accepted: 03/17/2022] [Indexed: 11/19/2022]
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12
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Pereira N, Chung PH, Kligman I, Rosenwaks Z. Clinical pregnancy resulting from intracytoplasmic sperm injection of prematurely ovulated oocytes retrieved from the posterior cul-de-sac. F S Rep 2021; 2:448-453. [PMID: 34934986 PMCID: PMC8655416 DOI: 10.1016/j.xfre.2021.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 08/08/2021] [Accepted: 08/10/2021] [Indexed: 12/02/2022] Open
Abstract
Objective To report a clinical pregnancy resulting from intracytoplasmic sperm injection of prematurely ovulated oocytes retrieved from the posterior cul-de-sac. Design Case report. Setting Academic center. Patient(s) A 40-year-old nulligravid woman underwent ovarian stimulation for in vitro fertilization (IVF). Daily injections of gonadotropin-releasing hormone antagonist were initiated on cycle day 8. A 10,000 IU dose of human chorionic gonadotropin was administered on cycle day 15 to trigger follicular maturation. The estradiol and luteinizing hormone levels on the trigger day were 1528 pg/mL and 2.4 mIU/mL, respectively. The patient underwent oocyte retrieval 35 hours after the trigger. Transvaginal sonography at the time of the retrieval revealed a large pocket of free fluid in the posterior cul-de-sac. Only 3 follicles measuring 10–12 mm were noted in both ovaries. No lead follicles were visualized. Intervention(s) Aspiration of free fluid from the posterior cul-de-sac. Main Outcome Measure(s) Clinical pregnancy. Result(s) The fluid in the posterior cul-de-sac was aspirated, and 3 mature oocytes were retrieved. Aspiration of the smaller ovarian follicles measuring 10–12 mm did not yield oocytes. All mature oocytes retrieved from the posterior cul-de-sac were fertilized with intracytoplasmic sperm injection. Three cleavage-stage embryos were transferred 3 days later. A single intrauterine pregnancy with cardiac activity was confirmed at a gestational age of 7 weeks. Conclusion(s) In the setting of premature ovulation, aspiration of free fluid from the posterior cul-de-sac can result in the retrieval of mature oocytes, which may result in clinical pregnancies.
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Affiliation(s)
- Nigel Pereira
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medicine, New York, New York
| | - Pak H Chung
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medicine, New York, New York
| | - Isaac Kligman
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medicine, New York, New York
| | - Zev Rosenwaks
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medicine, New York, New York
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13
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Taiyeb AM, Haji AI, Ibraheem ZO, Alsakkal GS. Pregnancy outcomes following different protocols of controlled ovarian hyperstimulation in couples undergoing intrauterine insemination. Clin Exp Pharmacol Physiol 2021; 48:1070-1079. [PMID: 33852746 DOI: 10.1111/1440-1681.13506] [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: 07/01/2020] [Accepted: 04/09/2021] [Indexed: 11/28/2022]
Abstract
Clomiphene citrate (CC), letrozole and cetrorelix acetate are frequently used agents in controlled ovarian hyperstimulation (COH). However, these three agents have not yet been compared to one another regarding their pregnancy outcomes. The present study was designed to retrospectively compare pregnancy outcomes among the three aforementioned agents. This study involved infertile couples with an infertility duration of at least 2 years, ages 18 to 42 years and who were referred to have their first intrauterine insemination (IUI) treatment cycle. All patients underwent COH with recombinant follicle-stimulating hormone (rFSH) plus CC (n = 118), letrozole (n = 81), or cetrorelix acetate (n = 62), followed by IUI. Using the one-way multivariate analysis of covariance to control female patients' ages, patients stimulated with cetrorelix acetate/rFSH or CC/rFSH had higher numbers of preovulatory follicles than women stimulated with letrozole/rFSH (P < .02), whereas women stimulated with cetrorelix acetate/rFSH had a thicker endometrium than women stimulated with CC/rFSH (P < .0005). Biochemical pregnancy rates were similar among the three protocols of COH. However, women stimulated with letrozole/rFSH showed clinical pregnancy rates higher than those stimulated with CC/rFSH (P = .003) or cetrorelix acetate/rFSH (P = .03) and subclinical abortion rates lower than those stimulated with CC/rFSH or cetrorelix acetate/rFSH (P = .009). Of the different protocols of COH, the odds of having a clinical pregnancy was 3.1 times greater for women stimulated with letrozole/rFSH than women stimulated with CC/rFSH (P = .004) and 2.8 times greater for women stimulated with letrozole/rFSH than women stimulated with cetrorelix acetate/rFSH (P = .03). Our observations show that increased numbers of preovulatory follicles or endometrium thickness do not necessarily improve pregnancy outcomes, because pregnancy outcomes are also subjected to the type of COH used agent. In this regard, letrozole produced fewer preovulatory follicles and did not significantly increase endometrium thickness, but significantly improved pregnancy outcomes in comparison to CC and cetrorelix acetate.
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Affiliation(s)
- Ahmed M Taiyeb
- College of Pharmacy, Almaaqal University, Basrah, Iraq
- Barz IVF Center for Embryo Research and Infertility Treatment, Erbil, Iraq
| | - Azheen I Haji
- Barz IVF Center for Embryo Research and Infertility Treatment, Erbil, Iraq
- Department of Obstetrics and Gynecology, College of Medicine, Hawler Medical University, Erbil, Iraq
| | - Zaid O Ibraheem
- Department of Pharmacy, Al Rafidain University College, Baghdad, Iraq
| | - Ghada S Alsakkal
- Department of Obstetrics and Gynecology, College of Medicine, Hawler Medical University, Erbil, Iraq
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14
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Ozgur K, Berkkanoglu M, Bulut H, Tore H, Donmez L, Coetzee K. Dydrogesterone versus medroxyprogesterone acetate co-treatment ovarian stimulation for IVF: a matched cohort study of 236 freeze-all-IVF cycles. J OBSTET GYNAECOL 2021; 42:268-275. [PMID: 33892620 DOI: 10.1080/01443615.2021.1873924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This matched cohort study was retrospectively performed, with cycles extracted from freeze-all-IVF treatments performed between March and November 2019, to compare the efficacy of flexible-start dydrogesterone (DYG) co-treatment ovarian stimulations (OS) with flexible-start medroxyprogesterone acetate (MPA) co-treatment OS. DYG cycles were matched 1:1 with MPA cycles using female age and antral follicle count, resulting in 236 matched cycles. OS durations and total FSH doses were similar in DYG and MPA OS cycles. The numbers of mature oocytes retrieved were similar; however, the mature oocyte retrieval rate was significantly lower (66.7 vs. 78.2%; p = .001) and the cycle cancellation rates were higher (29.2 vs. 21.2%; p = .056) in DYG co-treatments. A linear regression selected OS co-treatment protocol (0.53 DYG (0.356-0.776), p = .001) into the final model to predict a ≥ 80% mature oocyte retrieval rate. The per transfer (47.2 vs. 49.7; p = .721) and per treatment ongoing pregnancy rates (32.2 vs. 38.1%, p = .210) were similar in the two co-treatment groups. Flexible-start DYG co-treatment OS was as effective in blastocyst freeze-all-IVF cycles as MPA co-treatment, with similar ongoing pregnancy rates; however, mature oocyte retrieval was significantly decreased and cycle cancellation increased in DYG cycles.Impact statementWhat is already known on this subject? Progestin (i.e. artificial progesterone) co-treatment has long been known to be a feasible alternative to conventional GnRH-analogue co-treatment in OS for IVF, because of the long-standing evidence that progestin formulations have in oral contraceptive therapies. The recent evolution of effective freeze-all-IVF (in which high mid-cycle progesterone levels is not of concern because of the postponement of embryo transfer) has now made it possible to investigate progestin co-treatment OS in IVF.What do the results of this study add? Ongoing pregnancy rates from blastocyst frozen embryo transfers in flexible-start dydrogesterone (DYG) co-treatment ovarian stimulation (OS) cycles were similar to rates in flexible-start medroxyprogesterone acetate (MPA) co-treatment OS cycles. The mature oocyte retrieval rate was significantly lower and the cycle cancellation rate higher in DYG than in MPA cycles.What are the implications of these findings for clinical practice and/or further research? The evidence suggests that MPA co-treatment should be preferred in OS for IVF. Further investigation is required to refine progestin co-treatment protocols, because of their potential to reduce the number of viable blastocysts.
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Affiliation(s)
| | | | | | | | - Levent Donmez
- Department of Public Health, Medical Faculty, Akdeniz University, Antalya, Turkey
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15
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Zhang D, Zhang D, Sun Z, Deng C, Yu Q, Zhen J. The effect of a transient premature luteinizing hormone surge without elevated serum progesterone on in vitro fertilization outcomes in a gonadotropin-releasing hormone antagonist flexible protocol. Gynecol Endocrinol 2020; 36:550-553. [PMID: 31829082 DOI: 10.1080/09513590.2019.1683730] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
During controlled ovarian stimulation, the LH rising before triggering can lead to follicular luteinizations. However, LH can be suppressed immediately and no progesterone elevation with GnRH antagonist. This study retrospectively compared fresh IVF/ICSI cycle outcomes in antagonist protocols between the group with and the group without a premature LH surge. Logistic regression models were fitted to reduce the relevant confounders. Compared between premature LH surge group and control group, the implantation rates were 12.9% (30/233) vs 25.0% (141/536), p = .000; clinical pregnancy rates were 21.0% (25/119) vs 41.6% (119/286), p = .000; live birth rates were17.6% (21/119) vs 29.7% (85/286), p = .012. After adjusting for age, BMI, bFSH, and infertility factors, the adverse effects were still as pronounced for the clinical pregnancy rate (OR = 0.39, 95% CI = 0.24-0.66) and live birth rates (OR = 0.54, 95% CI = 0.32-0.93. In a GnRH antagonist flexible protocol, a transient premature LH surge which can be suppressed immediately after the initiation of antagonist without elevated serum progesterone, will cause a detrimental effect on the development of the embryo and IVF/ICSI pregnancy outcomes in fresh embryo transfer cycles.
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Affiliation(s)
- Duoduo Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital (PUMCH), Beijing, People's Republic of China
| | - Dan Zhang
- Department of Reproductive Medicine Center, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Zhengyi Sun
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital (PUMCH), Beijing, People's Republic of China
| | - Chengyan Deng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital (PUMCH), Beijing, People's Republic of China
| | - Qi Yu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital (PUMCH), Beijing, People's Republic of China
| | - Jingran Zhen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital (PUMCH), Beijing, People's Republic of China
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16
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Ulipristal Acetate Efficacy in a Patient with Symptomatic Fibroid and Concomitant Pulmonary Embolism. Case Rep Med 2020; 2020:3249268. [PMID: 32148512 PMCID: PMC7057005 DOI: 10.1155/2020/3249268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 02/03/2020] [Indexed: 11/23/2022] Open
Abstract
Ulipristal acetate (UPA) is an effective drug for the treatment of symptomatic uterine fibroids. The drug is highly effective in controlling bleeding control and in the recovery of anemia. Here, we report the case of a woman with severe menorrhagia due to a uterine fibroid and with concomitant pulmonary embolism, a serious life-threatening condition. UPA was shown to be effective in reducing fibroid volume and controlling symptoms, without worsening the underlying embolic disease. No adverse events were observed, and the patient has completely recovered.
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17
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Takeshige Y, Hashimoto T, Kyono K. Dose-Dependent Chlormadinone Acetate Can Suppress Premature LH Surge in Parallel with LH Value Reduction. FERTILITY & REPRODUCTION 2020. [DOI: 10.1142/s2661318220500048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Progestin-primed ovarian stimulation (PPOS) protocol is reported as an alternative method of premature luteinizing hormone (LH) surge suppression. How much dosage of chlormadinone acetate (CMA), a synthetic progestin, is appropriate treatment for this phenomenon? Methods: Retrospective case control study was performed at private assisted reproductive technology (ART) clinic in Japan. Collected data was 231 cycles in patients who underwent either PPOS protocol using 12, 6, 4, or 2 mg of CMA, groups 6C, 3C, 2C, and 1C, respectively (total, 113 cycles), or gonadotropin-releasing hormone (GnRH) antagonist protocol, groups 6A, 3A, 2A, and 1A, respectively (total, 118 cycles). In the CMA group, CMA and human menopausal gonadotropin (hMG) or follicle-stimulating hormone (FSH) were administered simultaneously beginning on menstrual cycle day 3. Serum P, E2, and LH were determined on the day of human chorionic gonadotropin (hCG) administration. Occurrence of premature LH surge was compared between two groups. Pregnancy outcomes were also calculated. Results: Premature LH surge was completely suppressed in CMA groups 6C, 3C, and 2C. On the other hand, this phenomenon was detected in antagonist method groups (5.9%, 7/118). But spontaneous ovulation was not observed in any group, and clinical outcomes are equal to those of GnRH antagonist treatment. Conclusions: Controlled ovarian stimulation (COS) using CMA can be an appropriate alternative progestin for PPOS protocol. Since CMA is an oral medication, this method can be easy to conduct and cost-effective compared with the antagonist method. From our observation, we suggest 4 mg/day of CMA can control the egg retrieval cycle without LH surge occurrence as in other PPOS methods.
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18
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Behery MA, Hasan EA, Ali EA, Eltabakh AA. Comparative study between agonist and antagonist protocols in PCOS patients undergoing ICSI: a cross-sectional study. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2019. [DOI: 10.1186/s43043-019-0002-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Lankreijer K, D'Hooghe TM, Apers S, Sermeus W, Repping S, Dancet EA. Hormonal medication in medically assisted reproduction: a systematic review of assessments from patients. Reprod Biomed Online 2019; 38:341-363. [PMID: 30770286 DOI: 10.1016/j.rbmo.2018.12.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 12/13/2018] [Accepted: 12/21/2018] [Indexed: 11/19/2022]
Abstract
Several hormonal fertility medications have comparable effectiveness. A literature review was conducted into patients' assessments regarding seven medication characteristics including 'side effects' and 'ease of use'. Medline, CINAHL and PsycINFO were searched for female fertility patients' written assessments of a hormonal medication. The tools used were appraised and common (i.e. ≥10%) unpleasant consequences were distinguished from rare ones. The 35 eligible studies did not rely on valid and reliable tools and did not provide patient assessments regarding all seven medication characteristics for any of the globally used medications. Evidence on medications for oocyte triggering was absent and for induction of pituitary quiescence it was scarce. Regarding medications for ovarian stimulation and luteal support, evidence on general side effects (mostly headache), local side effects (mostly pain), 'interference with home life' and 'impact on psychological wellbeing' was found. Evidence on 'ease of use' and 'required education' was only identified for medication for ovarian stimulation. Evidence on 'interference with work life' and 'compliance worry' was absent. This review calls for randomized controlled trials questioning patients with valid and reliable tools. In the meantime, this review's summary of the best available evidence can be integrated in decision aids facilitating personalized and informed medication choices.
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Affiliation(s)
- Kay Lankreijer
- Centre for Reproductive Medicine, Women's and Children's Hospital, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Thomas M D'Hooghe
- University of Leuven, Department of Development and Regeneration, Leuven, Belgium; Adjunct Professor, Department of Obstetrics, Gynecology and Reproductive Sciences Yale School of Medicine, New Haven, CT, USA; Vice-President and Head, Global Medical Affairs Fertility, Research and Development, Merck KGaA, Darmstadt, Germany
| | - Silke Apers
- University of Leuven, Department of Development and Regeneration, Leuven, Belgium; University of Leuven, Department of Public Health and Primary Care, Leuven, Belgium
| | - Walter Sermeus
- University of Leuven, Department of Public Health and Primary Care, Leuven, Belgium
| | - Sjoerd Repping
- Centre for Reproductive Medicine, Women's and Children's Hospital, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Eline Af Dancet
- Centre for Reproductive Medicine, Women's and Children's Hospital, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands; University of Leuven, Department of Development and Regeneration, Leuven, Belgium; University of Leuven, Department of Public Health and Primary Care, Leuven, Belgium; Research Foundation Flanders, Belgium.
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Eftekhar M, Bagheri RB, Neghab N, Hosseinisadat R. Evaluation of pretreatment with Cetrotide in an antagonist protocol for patients with PCOS undergoing IVF/ICSI cycles: a randomized clinical trial. JBRA Assist Reprod 2018; 22:238-243. [PMID: 29969209 PMCID: PMC6106631 DOI: 10.5935/1518-0557.20180039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Accepted: 06/11/2018] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE This study aimed to evaluate the effect of three days of GnRH antagonist pretreatment on the pregnancy outcomes of women with polycystic ovarian syndrome (PCOS) on GnRH antagonist protocols for IVF/ICSI. METHODS Fifty women with PCOS in the control group received conventional antagonist protocols, starting on day 2 of the cycle. In the pretreatment group (n=38), a GnRH antagonist was administered from day 2 of the menstrual cycle for three days. RESULTS Controlled ovarian stimulation (COS) duration and gonadotropin dosages were similar in both groups. The number of metaphase II (MII) oocytes, 2PN oocytes, embryos, along with implantation and clinical pregnancy rates, were higher in the pretreatment group when compared with controls, although the increment was not significant (P value ≥0.05). The chemical pregnancy rate was significantly higher in the pretreatment group. The rate of OHSS was significantly lower in the pretreatment than in the control group. CONCLUSION Women with PCOS offered early follicular phase GnRH antagonist pretreatment for three consecutive days had significantly fewer cases of OHSS and higher chemical pregnancy rates. There were trends toward greater numbers of MII oocytes, 2PN oocytes, and embryos, and higher clinical pregnancy rates in the pretreatment group.
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Affiliation(s)
- Maryam Eftekhar
- Reasearch and Clinical Center for Infertility, Yazd
Reproductive Sciences Institute, Shahid Sadoughi University of Medical Sciences,
Yazd, Iran
- Recurrent Abortion Research Center, Yazd Reproductive
Sciences Institute, Shahid Sadoughi University of Medical Sciences, Yazd,
Iran
| | - Ramesh Baradaran Bagheri
- Reasearch and Clinical Center for Infertility, Yazd
Reproductive Sciences Institute, Shahid Sadoughi University of Medical Sciences,
Yazd, Iran
- Recurrent Abortion Research Center, Yazd Reproductive
Sciences Institute, Shahid Sadoughi University of Medical Sciences, Yazd,
Iran
| | - Nosrat Neghab
- Reasearch and Clinical Center for Infertility, Yazd
Reproductive Sciences Institute, Shahid Sadoughi University of Medical Sciences,
Yazd, Iran
- Recurrent Abortion Research Center, Yazd Reproductive
Sciences Institute, Shahid Sadoughi University of Medical Sciences, Yazd,
Iran
| | - Robabe Hosseinisadat
- Department of Obstetrics and Gynecology, School of
Medicine, Kerman University of Medical Sciences, Kerman, Iran
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21
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Lambalk CB, Banga FR, Huirne JA, Toftager M, Pinborg A, Homburg R, van der Veen F, van Wely M. GnRH antagonist versus long agonist protocols in IVF: a systematic review and meta-analysis accounting for patient type. Hum Reprod Update 2018; 23:560-579. [PMID: 28903472 DOI: 10.1093/humupd/dmx017] [Citation(s) in RCA: 213] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 06/19/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Most reviews of IVF ovarian stimulation protocols have insufficiently accounted for various patient populations, such as ovulatory women, women with polycystic ovary syndrome (PCOS) or women with poor ovarian response, and have included studies in which the agonist or antagonist was not the only variable between the compared study arms. OBJECTIVE AND RATIONALE The aim of the current study was to compare GnRH antagonist protocols versus standard long agonist protocols in couples undergoing IVF or ICSI, while accounting for various patient populations and treatment schedules. SEARCH METHODS The Cochrane Menstrual Disorders and Subfertility Review Group specialized register of controlled trials and Pubmed and Embase databases were searched from inception until June 2016. Eligible trials were those that compared GnRH antagonist protocols and standard long GnRH agonist protocols in couples undergoing IVF or ICSI. The primary outcome was ongoing pregnancy rate. Secondary outcomes were: live birth rate, clinical pregnancy rate, number of oocytes retrieved and safety with regard to ovarian hyperstimulation syndrome (OHSS). Separate comparisons were performed for the general IVF population, women with PCOS and women with poor ovarian response. Pre-planned subgroup analyses were performed for various antagonist treatment schedules. OUTCOMES We included 50 studies. Of these, 34 studies reported on general IVF patients, 10 studies reported on PCOS patients and 6 studies reported on poor responders. In general IVF patients, ongoing pregnancy rate was significantly lower in the antagonist group compared with the agonist group (RR 0.89, 95% CI 0.82-0.96). In women with PCOS and in women with poor ovarian response, there was no evidence of a difference in ongoing pregnancy between the antagonist and agonist groups (RR 0.97, 95% CI 0.84-1.11 and RR 0.87, 95% CI 0.65-1.17, respectively). Subgroup analyses for various antagonist treatment schedules compared to the long protocol GnRH agonist showed a significantly lower ongoing pregnancy rate when the oral hormonal programming pill (OHP) pretreatment was combined with a flexible protocol (RR 0.74, 95% CI 0.59-0.91) while without OHP, the RR was 0.84, 95% CI 0.71-1.0. Subgroup analysis for the fixed antagonist schedule demonstrated no evidence of a significant difference with or without OHP (RR 0.94, 95% CI 0.79-1.12 and RR 0.94, 95% CI 0.83-1.05, respectively). Antagonists resulted in significantly lower OHSS rates both in the general IVF patients and in women with PCOS (RR 0.63, 95% CI 0.50-0.81 and RR 0.53, 95% CI 0.30-0.95, respectively). No data on OHSS was available from trials in poor responders. WIDER IMPLICATIONS In a general IVF population, GnRH antagonists are associated with lower ongoing pregnancy rates when compared to long protocol agonists, but also with lower OHSS rates. Within this population, antagonist treatment prevents one case of OHSS in 40 patients but results in one less ongoing pregnancy out of every 28 women treated. Thus standard use of the long GnRH agonist treatment is perhaps still the approach of choice for prevention of premature luteinization. In couples with PCOS and poor responders, GnRH antagonists do not seem to compromise ongoing pregnancy rates and are associated with less OHSS and therefore could be considered as standard treatment.
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Affiliation(s)
- C B Lambalk
- Division of Reproductive Medicine, Department of Obstetrics and Gynaecology, VU University medical centre (VUmc), PO Box 7075, 1007 MB, Amsterdam, the Netherlands
| | - F R Banga
- Division of Reproductive Medicine, Department of Obstetrics and Gynaecology, VU University medical centre (VUmc), PO Box 7075, 1007 MB, Amsterdam, the Netherlands
| | - J A Huirne
- Division of Reproductive Medicine, Department of Obstetrics and Gynaecology, VU University medical centre (VUmc), PO Box 7075, 1007 MB, Amsterdam, the Netherlands
| | - M Toftager
- Department of Obstetrics & Gynaecology, Fertility Clinic Section 455, Hvidovre University Hospital, Kettegård Alle 30, Hvidovre, Copenhagen 2650, Denmark
| | - A Pinborg
- Department of Obstetrics & Gynaecology, Fertility Clinic Section 455, Hvidovre University Hospital, Kettegård Alle 30, Hvidovre, Copenhagen 2650, Denmark
| | - R Homburg
- Homerton University Hospital NHS Foundation Trust, Homerton Row, Hackney, London E9 6SR, UK
| | - F van der Veen
- Center for Reproductive Medicine, Department of Obstetrics and Gynaecology, Academic Medical Center, University of Amsterdam, PO Box 227000, 1100 DE, Amsterdam, The Netherlands
| | - M van Wely
- Center for Reproductive Medicine, Department of Obstetrics and Gynaecology, Academic Medical Center, University of Amsterdam, PO Box 227000, 1100 DE, Amsterdam, The Netherlands
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Yu S, Long H, Chang HYN, Liu Y, Gao H, Zhu J, Quan X, Lyu Q, Kuang Y, Ai A. New application of dydrogesterone as a part of a progestin-primed ovarian stimulation protocol for IVF: a randomized controlled trial including 516 first IVF/ICSI cycles. Hum Reprod 2017; 33:229-237. [PMID: 29300975 DOI: 10.1093/humrep/dex367] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 12/08/2017] [Indexed: 12/23/2022] Open
Affiliation(s)
- Sha Yu
- Department of Assisted Reproduction, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Zhizaoju Road No. 639, Huangpu District, Shanghai 200011, People’s Republic of China
| | - Hui Long
- Department of Assisted Reproduction, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Zhizaoju Road No. 639, Huangpu District, Shanghai 200011, People’s Republic of China
| | - Hannah Ya-ning Chang
- Department of Assisted Reproduction, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Zhizaoju Road No. 639, Huangpu District, Shanghai 200011, People’s Republic of China
| | - Yali Liu
- Department of Assisted Reproduction, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Zhizaoju Road No. 639, Huangpu District, Shanghai 200011, People’s Republic of China
| | - Hongyuan Gao
- Department of Assisted Reproduction, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Zhizaoju Road No. 639, Huangpu District, Shanghai 200011, People’s Republic of China
| | - Jing Zhu
- Department of Assisted Reproduction, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Zhizaoju Road No. 639, Huangpu District, Shanghai 200011, People’s Republic of China
| | - Xinxin Quan
- Department of Assisted Reproduction, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Zhizaoju Road No. 639, Huangpu District, Shanghai 200011, People’s Republic of China
| | - Qifeng Lyu
- Department of Assisted Reproduction, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Zhizaoju Road No. 639, Huangpu District, Shanghai 200011, People’s Republic of China
| | - Yanping Kuang
- Department of Assisted Reproduction, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Zhizaoju Road No. 639, Huangpu District, Shanghai 200011, People’s Republic of China
- Shanghai Key Laboratory of Reproductive Medicine, Shanghai Jiao Tong University School of Medicine, South Chongqing Road No. 280, Huangpu District, Shanghai 200025, People’s Republic of China
| | - Ai Ai
- Department of Assisted Reproduction, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Zhizaoju Road No. 639, Huangpu District, Shanghai 200011, People’s Republic of China
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Gat I, AlKudmani B, Wong K, Zohni K, Weizman NF, Librach C, Sharma P. Significant correlation between anti-müllerian hormone and embryo euploidy in a subpopulation of infertile patients. Reprod Biomed Online 2017; 35:602-608. [PMID: 28826601 DOI: 10.1016/j.rbmo.2017.06.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 06/24/2017] [Accepted: 06/27/2017] [Indexed: 11/30/2022]
Abstract
Anti-Müllerian hormone (AMH) is a standard marker of ovarian reserve. Correlation between AMH and egg euploidy is controversial. We evaluated the association between AMH and blastocyst euploidy rate examined by pre-implantation genetic screening (PGS). This retrospective study was conducted at the CReATe Fertility Centre. We included single IVF cycles of 216 infertile couples, which resulted in 911 blastocysts subjected to array comparative genomic hybridization and evaluated IVF outcome after embryo transfer. The average age and median AMH of female patients were 37.2 (SD = 3.8) and 20 pmol/l, respectively, and the average euploidy rate was 38.3%. Using multivariate regression controlling for age, antral follicle count, body mass index and parity, there was a significant association between serum AMH and proportion of euploid embryos (P = 0.02), due to the dominant ≤36 age group in which significant correlation between AMH and euploidy rate (P = 0.02) was demonstrated. Clinical outcome was similar, including biochemical, clinical and ongoing pregnancy rates as well as pregnancy loss. This study shows a correlation between AMH and aneuploidy rate, specifically among infertile patients younger than 37 years old. Study limitations are discussed.
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Affiliation(s)
- Itai Gat
- CReATe Fertility Centre, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada; Department of Gynecology, Women's College Hospital, Toronto, Ontario, Canada; Pinchas Borenstein Talpiot Medical Leadership Program, Sheba Medical Centre, Tel Hashomer, Israel; Sackler Medical School, Tel Aviv University, Tel Aviv, Israel.
| | - Basheer AlKudmani
- CReATe Fertility Centre, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada; Department of Gynecology, Women's College Hospital, Toronto, Ontario, Canada
| | - Karen Wong
- CReATe Fertility Centre, Toronto, Ontario, Canada
| | - Khaled Zohni
- CReATe Fertility Centre, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada; Department of Gynecology, Women's College Hospital, Toronto, Ontario, Canada
| | - Noga Fuchs Weizman
- CReATe Fertility Centre, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada; Department of Gynecology, Women's College Hospital, Toronto, Ontario, Canada
| | - Clifford Librach
- CReATe Fertility Centre, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada; Department of Gynecology, Women's College Hospital, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Prati Sharma
- CReATe Fertility Centre, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada; Department of Gynecology, Women's College Hospital, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Wang R, Lin S, Wang Y, Qian W, Zhou L. Comparisons of GnRH antagonist protocol versus GnRH agonist long protocol in patients with normal ovarian reserve: A systematic review and meta-analysis. PLoS One 2017; 12:e0175985. [PMID: 28437434 PMCID: PMC5402978 DOI: 10.1371/journal.pone.0175985] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 04/03/2017] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To evaluate the effectiveness and safety of gonadotropin-releasing hormone antagonist (GnRH-ant) protocol and gonadotropin-releasing hormone agonist (GnRH-a) long protocol in patients with normal ovarian reserve. METHODS We searched the PubMed (1992-2016), Cochrane Library (1999-2016), Web of Science (1950-2016), Chinese Biomedical Database (CBM, 1979-2016), and China National Knowledge Infrastructure (CNKI, 1994-2016). Any randomized controlled trials (RCTs) that compared GnRH-ant protocol and GnRH-a long protocol in patients with normal ovarian reserve were included, and data were extracted independently by two reviewers. The meta-analysis was performed by Revman 5.3 software. RESULTS Twenty-nine RCTs (6399 patients) were included in this meta-analysis. Stimulation days (mean difference (MD) [95% confidence interval (CI)] = -0.8 [-1.36, -0.23], P = 0.006), gonadotrophin (Gn) dosage (MD [95% CI] = -3.52 [-5.56, -1.48], P = 0.0007), estradiol (E2) level on the day of human chorionic gonadotrophin (HCG) administration (MD [95% CI] = -365.49 [-532.93, -198.05], P<0.0001), the number of oocytes retrieved (MD [95% CI] = -1.41 [-1.84, -0.99], P<0.00001), the embryos obtained (MD [95% CI] = -0.99 [-1.38, -0.59], P<0.00001), incidence of ovarian hyperstimulation syndrome (OHSS) (OR [95% CI] = 0.69 [0.57, 0.83], P<0.0001) were statistically significantly lower in GnRH-ant protocol than GnRH-a long protocol. However, the clinical pregnancy rate (OR [95% CI] = 0.90 [0.80, 1.01], P = 0.08), ongoing pregnancy rate (OR [95% CI] = 0.88 [0.77, 1.00], P = 0.05), live birth rate (OR [95% CI] = 0.95 [0.74, 1.09], P = 0.27), miscarriage rate (OR [95% CI] = 0.98 [0.69, 1.40], P = 0.93), and cycle cancellation rate (OR [95% CI] = 0.86 [0.52, 1.44], P = 0.57) showed no significant differences between the two groups. CONCLUSION GnRH-ant protocol substantially decreased the incidence of OHSS without influencing the pregnancy rate and live birth rate compared to GnRH-a long protocol among patients with normal ovarian reserve.
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Affiliation(s)
- Ruolin Wang
- Reproductive Medical Center, Peking University Shenzhen Hospital, Shenzhen, China
- Medical College of Shantou University, Shantou, China
| | - Shouren Lin
- Reproductive Medical Center, Peking University Shenzhen Hospital, Shenzhen, China
| | - Yong Wang
- Reproductive Medical Center, Peking University Shenzhen Hospital, Shenzhen, China
| | - Weiping Qian
- Reproductive Medical Center, Peking University Shenzhen Hospital, Shenzhen, China
| | - Liang Zhou
- Reproductive Medical Center, Peking University Shenzhen Hospital, Shenzhen, China
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Ponzano A, Colangelo EC, Di Biase L, Romani F, Tiboni GM. Clinical experience with an ovarian stimulation protocol for intrauterine insemination adopting a gonadotropin releasing hormone antagonist at low dose. Gynecol Endocrinol 2017; 33:208-211. [PMID: 27922279 DOI: 10.1080/09513590.2016.1252327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Studies testing the effectiveness of GnRH antagonists in controlled ovarian stimulation (COS) for intrauterine insemination (IUI) have provided controversial results. The present study was undertaken to evaluate, whether the use of a half of the conventional dose of the GnRH antagonist cetrorelix can be effective in increasing the successful rate of IUI cycles. Patients started COS with human menopausal gonadotropin (hMG) on day three of the menstrual cycle. Cetrorelix was started when at least one follicle of ≥14 mm, was detected at the ultrasound scan, according to the flexible multiple daily dose protocol, and continued until the trigger day with recombinant hCG. Patients adopting GnRH antagonist at low dose had a pregnancy rate (21.7%) that was significantly higher (p < 0.05) in comparison to women receiving hMG only (8.7%). These results suggest that adding a reduced dose of GnRH antagonist to the COS for IUI cycles significantly improves the outcome of the procedure.
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Affiliation(s)
- Adalisa Ponzano
- a Department of Medicine and Aging Sciences , University "G. d'Annunzio" of Chieti-Pescara , Chieti , Italy
| | - Enrica Concetta Colangelo
- a Department of Medicine and Aging Sciences , University "G. d'Annunzio" of Chieti-Pescara , Chieti , Italy
| | - Lucia Di Biase
- a Department of Medicine and Aging Sciences , University "G. d'Annunzio" of Chieti-Pescara , Chieti , Italy
| | - Federica Romani
- a Department of Medicine and Aging Sciences , University "G. d'Annunzio" of Chieti-Pescara , Chieti , Italy
| | - Gian Mario Tiboni
- a Department of Medicine and Aging Sciences , University "G. d'Annunzio" of Chieti-Pescara , Chieti , Italy
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Lin PY, Huang FJ, Kung FT, Lin YC, Chiang HJ, Lin YJ, Lan KC. Reassessing the feasibility of the zygote score for predicting embryo viability in IVF/ICSI using the GnRH antagonist protocol compared to the long protocol. PLoS One 2017; 12:e0171465. [PMID: 28152037 PMCID: PMC5289632 DOI: 10.1371/journal.pone.0171465] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 01/03/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Many factors from the oocyte/sperm or the process of fertilization may affect the zygote formation. The zygote score (Z-score) describes the quality of a human zygote based on its pronuclear morphology, nucleolar precursor bodies, and alignment of polar bodies, and it can be used in the selection process at the zygote stage for embryo transfer or cryopreservation. OBJECTIVE The aim of this retrospective cohort study was to investigate the relationship between different controlled ovarian stimulation (COS) protocols and the zygote score (Z-score) and to assess the feasibility of the Z-score for predicting embryo survival in the GnRH-antagonist (GnRH-ant) protocol. METHODS It is a retrospective, single-center cohort study. A total of 3,826 zygotes with normal fertilization were analyzed from 744 in vitro fertilization /intra-cytoplasmic sperm injection (IVF/ICSI) cycles (long protocol n = 392; GnRH-ant n = 352) between Jan 2010 and April 2014 in the IVF unit of Chang-Gung Memorial Hospital Kaohsiung Medical Center. RESULTS The Z-score distribution differed significantly between these two protocols. The overall Z-score was poorer for zygotes from GnRH-ant cycles (p<0.05). Univariate and multivariate analyses indicated the type of COS protocol is one of the main determinants of Z-score grading. Our study found good-quality day 3 embryo/blastocyst formation and the cumulative embryo survival rate were correlated with the Z-score but not the COS protocol. With the GnRH-ant protocol, the number of Z1 in the transferred cohort embryos was significantly correlated with the clinical pregnancy rate (r = 0.976; p = 0.024) and live birth rate (r = 0.971; p = 0.029). This correlation was not seen with the long protocol. CONCLUSIONS The Z-score distribution for the GnRH antagonist cycles was poorer than that of the long protocol, but the Z-score system is a valuable parameter for predicting embryo viability in the GnRH-ant protocol, providing a strong correlation with the clinical pregnancy rate and live birth rate.
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Affiliation(s)
- Pin-Yao Lin
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Kaohsiung, Taiwan
| | - Fu-Jen Huang
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Fu-Tsai Kung
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yi-Chi Lin
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hsin-Ju Chiang
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Ju Lin
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kuo-Chung Lan
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- * E-mail:
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27
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Ganor-Paz Y, Friedler-Mashiach Y, Ghetler Y, Hershko-Klement A, Berkovitz A, Gonen O, Shulman A, Wiser A. What is the best treatment for women with polycystic ovarian syndrome and high LH/FSH ratio? A comparison among in vitro fertilization with GnRH agonist, GnRH antagonist and in vitro maturation. J Endocrinol Invest 2016; 39:799-803. [PMID: 26797707 DOI: 10.1007/s40618-015-0429-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 12/28/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE To evaluate whether high LH/FSH ratio has a clinical impact on patients with polycystic ovary syndrome (PCOS) undergoing in vitro fertilization (IVF) with GnRH-agonist/antagonist protocols or in vitro maturation (IVM) treatments. METHODS We retrospectively reviewed all PCOS patients with day 3 LH/FSH ratio ≥1.5 who underwent IVF or IVM. The main outcomes measures were embryo quality and pregnancy rate. RESULTS A total of 75 cycles were included. Among these, 44 patients underwent long agonist protocol, 16 antagonist protocol and 15 IVM. Age, basal LH and FSH levels, as well as duration of infertility were comparable for all groups. The LH level on the day of hCG administration was significantly lower in the antagonist group (0.9 IU/ml) compared to the long agonist group (1.4 IU/ml, p = 0.01). There was no difference in pregnancy rates among the groups: 27.2 % in the long agonist group, 37.5 % in the antagonist group and 26.6 % among the IVM patients. CONCLUSIONS High LH/FSH ratio had no adverse effect on pregnancy rates in all three treatment modes.
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Affiliation(s)
- Y Ganor-Paz
- Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tshernichovsky Street, Kfar Saba, Israel.
- Tel Aviv University, Tel Aviv, Israel.
| | - Y Friedler-Mashiach
- Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tshernichovsky Street, Kfar Saba, Israel
| | - Y Ghetler
- Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tshernichovsky Street, Kfar Saba, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - A Hershko-Klement
- Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tshernichovsky Street, Kfar Saba, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - A Berkovitz
- Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tshernichovsky Street, Kfar Saba, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - O Gonen
- Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tshernichovsky Street, Kfar Saba, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - A Shulman
- Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tshernichovsky Street, Kfar Saba, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - A Wiser
- Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tshernichovsky Street, Kfar Saba, Israel
- Tel Aviv University, Tel Aviv, Israel
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28
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Hu X, Luo Y, Huang K, Li Y, Xu Y, Zhou C, Mai Q. New Perspectives on Criteria for the Determination of HCG Trigger Timing in GnRH Antagonist Cycles. Medicine (Baltimore) 2016; 95:e3691. [PMID: 27196479 PMCID: PMC4902421 DOI: 10.1097/md.0000000000003691] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The aim of this study was to investigate 2 quantification criteria to evaluate the developmental condition of follicles cohort and clarify their impacts upon the determining of human chorionic gonadotropin trigger timing and the reproductive outcome: the proportion of mature follicles in growing follicles cohort on the day of human chorionic gonadotropin trigger and the peak estradiol level per oocyte on the day of human chorionic gonadotropin administration.Of the patients who underwent in vitro fertilization/ intracytoplasmic sperm injection-embryo transfer from 2011 to 2013, 492 controlled ovarian hyperstimulation cycles using gonadotropin-releasing hormone antagonists reaching the ovum pick-up and fresh embryo-transfer stage were included. Patients were divided into 3 groups according to their ≥17 mm/≥10 mm follicles ratio on the day of human chorionic gonadotropin administration (Low proportion: ≤30%, Middle proportion: 30%-60%, High proportion: ≥60%). Patients were divided into 5 groups according to their peak estradiol level/oocyte (Group A: <100 pg/mL per oocyte, Group B: 100-199 pg/mL per oocyte, Group C: 200-299 pg/mL per oocyte, Group D: 300-399 pg/mL per oocyte, Group E ≥400 pg/mL per oocyte) as well. Comparison among groups was made regarding ovarian stimulation characteristics, fertilization rate, good quality embryo rate, implantation, pregnancy, and live birth rates.On the basis of ≥17 mm/≥10 mm follicles ratio, the number of oocyte retrieved in low proportion group is more than other 2 groups. Implantation rate, clinical pregnancy, and live birth rate in high proportion group were 25.8%, 42.7%, and 31.1%, respectively, which is highest in 3 groups, and statistical significance existed between high and middle proportion groups. When the division is based on peak estradiol level/oocyte, the number of oocyte retrieved of ≥400 pg/mL per oocyte Group was significantly lowest compared with the other 4 groups. Matured ovum rate, fertilization rate, and good quality embryos rate exhibited an increasing trend as the peak estradiol level/oocyte increased. While pregnancy rate, implantation rate, and live birth rate were found to be lower whenever estradiol/oocyte ratio exceeded 400 pg/mL per oocyte or less than 100 pg/mL per oocyte, and there is statistical difference.Patients with the proportion of mature follicle reaching 60% on the day of human chorionic gonadotropin trigger and peak estradiol/oocyte level within 100∼399 pg/mL range can get a better pregnancy and implantation rate.
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Affiliation(s)
- Xiaokun Hu
- From the Reproductive Medicine Center, The First Affiliated Hospital of Sun Yat-sen University, Guangdong, China
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Al‐Inany HG, Youssef MA, Ayeleke RO, Brown J, Lam WS, Broekmans FJ. Gonadotrophin-releasing hormone antagonists for assisted reproductive technology. Cochrane Database Syst Rev 2016; 4:CD001750. [PMID: 27126581 PMCID: PMC8626739 DOI: 10.1002/14651858.cd001750.pub4] [Citation(s) in RCA: 129] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Gonadotrophin-releasing hormone (GnRH) antagonists can be used to prevent a luteinizing hormone (LH) surge during controlled ovarian hyperstimulation (COH) without the hypo-oestrogenic side-effects, flare-up, or long down-regulation period associated with agonists. The antagonists directly and rapidly inhibit gonadotrophin release within several hours through competitive binding to pituitary GnRH receptors. This property allows their use at any time during the follicular phase. Several different regimens have been described including multiple-dose fixed (0.25 mg daily from day six to seven of stimulation), multiple-dose flexible (0.25 mg daily when leading follicle is 14 to 15 mm), and single-dose (single administration of 3 mg on day 7 to 8 of stimulation) protocols, with or without the addition of an oral contraceptive pill. Further, women receiving antagonists have been shown to have a lower incidence of ovarian hyperstimulation syndrome (OHSS). Assuming comparable clinical outcomes for the antagonist and agonist protocols, these benefits would justify a change from the standard long agonist protocol to antagonist regimens. This is an update of a Cochrane review first published in 2001, and previously updated in 2006 and 2011. OBJECTIVES To evaluate the effectiveness and safety of gonadotrophin-releasing hormone (GnRH) antagonists compared with the standard long protocol of GnRH agonists for controlled ovarian hyperstimulation in assisted conception cycles. SEARCH METHODS We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched from inception to May 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, inception to 28 April 2015), Ovid MEDLINE (1966 to 28 April 2015), EMBASE (1980 to 28 April 2015), PsycINFO (1806 to 28 April 2015), CINAHL (to 28 April 2015) and trial registers to 28 April 2015, and handsearched bibliographies of relevant publications and reviews, and abstracts of major scientific meetings, for example the European Society of Human Reproduction and Embryology (ESHRE) and American Society for Reproductive Medicine (ASRM). We contacted the authors of eligible studies for missing or unpublished data. The evidence is current to 28 April 2015. SELECTION CRITERIA Two review authors independently screened the relevant citations for randomised controlled trials (RCTs) comparing different GnRH agonist versus GnRH antagonist protocols in women undergoing in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI). DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility and risk of bias, and extracted the data. The primary review outcomes were live birth and ovarian hyperstimulation syndrome (OHSS). Other adverse effects (miscarriage and cycle cancellation) were secondary outcomes. We combined data to calculate pooled odds ratios (ORs) and 95% confidence intervals (CIs). Statistical heterogeneity was assessed using the I(2) statistic. We assessed the overall quality of the evidence for each comparison using GRADE methods. MAIN RESULTS We included 73 RCTs, with 12,212 participants, comparing GnRH antagonist to long-course GnRH agonist protocols. The quality of the evidence was moderate: limitations were poor reporting of study methods.Live birthThere was no conclusive evidence of a difference in live birth rate between GnRH antagonist and long course GnRH agonist (OR 1.02, 95% CI 0.85 to 1.23; 12 RCTs, n = 2303, I(2)= 27%, moderate quality evidence). The evidence suggested that if the chance of live birth following GnRH agonist is assumed to be 29%, the chance following GnRH antagonist would be between 25% and 33%.OHSSGnRH antagonist was associated with lower incidence of any grade of OHSS than GnRH agonist (OR 0.61, 95% C 0.51 to 0.72; 36 RCTs, n = 7944, I(2) = 31%, moderate quality evidence). The evidence suggested that if the risk of OHSS following GnRH agonist is assumed to be 11%, the risk following GnRH antagonist would be between 6% and 9%.Other adverse effectsThere was no evidence of a difference in miscarriage rate per woman randomised between GnRH antagonist group and GnRH agonist group (OR 1.04, 95% CI 0.82 to 1.30; 33 RCTs, n = 7022, I(2) = 0%, moderate quality evidence).With respect to cycle cancellation, GnRH antagonist was associated with a lower incidence of cycle cancellation due to high risk of OHSS (OR 0.47, 95% CI 0.32 to 0.69; 19 RCTs, n = 4256, I(2) = 0%). However cycle cancellation due to poor ovarian response was higher in women who received GnRH antagonist than those who were treated with GnRH agonist (OR 1.32, 95% CI 1.06 to 1.65; 25 RCTs, n = 5230, I(2) = 68%; moderate quality evidence). AUTHORS' CONCLUSIONS There is moderate quality evidence that the use of GnRH antagonist compared with long-course GnRH agonist protocols is associated with a substantial reduction in OHSS without reducing the likelihood of achieving live birth.
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Affiliation(s)
- Hesham G Al‐Inany
- Faculty of Medicine, Cairo UniversityDepartment of Obstetrics & Gynaecology8 Moustapha Hassanin StManialCairoEgypt
| | - Mohamed A Youssef
- Faculty of Medicine, Cairo UniversityDepartment of Obstetrics & Gynaecology8 Moustapha Hassanin StManialCairoEgypt
| | - Reuben Olugbenga Ayeleke
- University of AucklandDepartment of Obstetrics and GynaecologyPrivate Bag 92019AucklandNew Zealand
| | - Julie Brown
- The University of AucklandLiggins InstitutePark RdGraftonAucklandNew Zealand1142
| | - Wai Sun Lam
- University of AucklandDepartment of Obstetrics and GynaecologyPrivate Bag 92019AucklandNew Zealand
| | - Frank J Broekmans
- University Medical CenterDepartment of Reproductive Medicine and GynecologyUtrechtNetherlands
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Toftager M, Bogstad J, Bryndorf T, Løssl K, Roskær J, Holland T, Prætorius L, Zedeler A, Nilas L, Pinborg A. Risk of severe ovarian hyperstimulation syndrome in GnRH antagonist versus GnRH agonist protocol: RCT including 1050 first IVF/ICSI cycles. Hum Reprod 2016; 31:1253-64. [PMID: 27060174 DOI: 10.1093/humrep/dew051] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 02/25/2016] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTION Is the risk of severe ovarian hyperstimulation syndrome (OHSS) similar in a short GnRH antagonist and long GnRH agonist protocol in first cycle IVF/ICSI patients less than 40 years of age?. SUMMARY ANSWER There is an increased risk of severe OHSS in the long GnRH agonist group compared with the short GnRH antagonist protocol. WHAT IS KNOWN ALREADY?: In the most recent Cochrane review, the GnRH antagonist protocol was associated with a similar live birth rate (LBR), a similar on-going pregnancy rate (OPR), and a lower incidence of OHSS (odds ratio (OR) = 0.43 95% confidence interval (CI): 0.33-0.57) compared with the traditional GnRH agonist protocol. Previous trials comparing the two protocols mainly included selected patient populations, a limited number of patients and the applied OHSS criteria differed, making direct comparisons difficult. In two recent large meta-analyses, no significant differences in LBR (OR = 0.86; 95% CI: 0.72-1.02) or in the incidence of severe OHSS were reported, while others found a lower LBR (OR = 0.82; 95% CI: 0.68-0.97) and a reduced risk of severe OHSS using the GnRH antagonist protocol (OR = 0.60; 95% CI: 0.40-0.88). STUDY DESIGN, SIZE, DURATION Phase IV, dual-centre, open-label, RCT including 1050 women allocated to either short GnRH antagonist or long GnRH agonist protocol in a 1:1 ratio and enrolled over a 5-year period using a web-based concealed randomization code. This is a superiority study designed to detect a difference in severe OHSS, the primary outcome, between the two groups with a power of 80% and stratified for age, assisted reproductive technology (ART) clinic and planned fertilization procedure (IVF/ICSI). The secondary aims were to compare rates of mild and moderate OHSS, positive plasma (p)-hCG, on-going pregnancy and live birth between the two arms. None of the women had undergone previous ART treatment. PARTICIPANTS/MATERIALS, SETTING, METHODS All infertile women referred for their first IVF/ICSI at two public fertility clinics, less than 40 years of age and with no uterine malformations were asked to participate. A total of 1099 subjects were randomized, including women with poor ovarian reserve, polycystic ovary syndrome and irregular cycles. A total of 49 women withdrew their consent, thus 1050 subjects were allocated to the GnRH antagonist (n = 534) and agonist protocol (n = 516), respectively. In total 1023 women started recombinant human follitropin-β (rFSH) stimulation, 528 in the GnRH antagonist group and 495 in the GnRH agonist group. All subjects were given a fixed rFSH dose of 150 IU or 225 IU according to age ≤36 years or >36 years, with the option to adjust dose at stimulation day 6. Clinical OHSS parameters were collected at oocyte retrieval, and Days 3 and 14 post-transfer. On-going pregnancy was determined by transvaginal ultrasonography at gestational weeks 7-9. In the intention-to-treat (ITT) analysis for reproductive outcomes, 1050 subjects were included. For the ITT analyses on OHSS 1023 subjects who started gonadotrophin stimulation were included. MAIN RESULTS AND THE ROLE OF CHANCE The incidence of severe OHSS [5.1% (27/528) versus 8.9% (44/495) (difference in proportion percentage point (Δpp) = -3.8pp; 95% CI: -7.1 to -0.4; P = 0.02)] and moderate OHSS [10.2% (54/528) versus 15.6% (77/495) (Δpp = -5.3pp; 95% CI: -9.6 to -1.0; P = 0.01) ] was significantly lower in the GnRH antagonist group compared with the agonist group, respectively. In the GnRH antagonist and agonist group, respectively, 4.7% (25/528) versus 8.5% (42/495) women were seen by a physician due to OHSS (P = 0.01), and 1.7% (9/528) versus 3.6% (18/495) were admitted to hospital due to OHSS (P = 0.06). No women had ascites-puncture in the GnRH antagonist group versus 2.0% (10/495) in the GnRH agonist group (P < 0.01). LBRs were 22.8% (122/534) versus 23.8% (123/516) (Δpp = -1.0pp; 95% CI: -6.3 to 4.3; P = 0.70) and OPRs were 24.9% (133/528) versus 26.2% (135/516) (Δpp = -1.3pp; 95% CI: -6.7 to 4.2; P = 0.64) per randomized subject in the GnRH antagonist versus agonist group, with a mean number of 1.1 versus 1.2 embryos transferred in the two groups. Pregnancy rates (PR) per randomized subject, per started gonadotrophin stimulation and per embryo transfer were all similar in the two groups. LIMITATIONS, REASONS FOR CAUTION A possible limitation is the duration of the trial, with new methods, such as 'freeze all' and 'GnRH agonist triggering', being developed during the trial, the new methods were sought avoided, however a total number of 32 women had 'freeze all' and 'GnRH agonist triggering' was performed in three cases. Ultrasonic measurements were performed by different physicians and inter-observer bias may be present. Measures of anti-Mullerian hormone and antral follicle count, to estimate ovarian reserve and thus predict risk of OHSS, were not performed. Finally, the physicians were not blinded to GnRH treatment group after randomization. WIDER IMPLICATIONS OF THE FINDINGS The short GnRH antagonist protocol should be the protocol of choice for patients undergoing their first ART cycle in females <40 years of age including both low and high responders when an age-dependent initially fixed gonadotrophin dose is used, as an increased risk of severe OHSS and the associated complications is seen in the long GnRH agonist group and as PRs and LBRs are similar in the two groups. Patients at risk of OHSS particularly benefit from the short GnRH antagonist treatment as GnRH agonist triggering can be used. STUDY FUNDING/COMPETING INTERESTS An unrestricted research grant is funded by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA (MSD). The funders had no influence on the data collection, analyses or conclusions of the study. No conflict of interests to declare. TRIAL REGISTRATION NUMBER EudraCT #: 2008-005452-24. ClinicalTrial.gov: NCT00756028. Trial registration date: 18 September 2008. Date of first patient's enrolment: 14 January 2009.
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Affiliation(s)
- M Toftager
- Department of Obstetrics & Gynaecology, Fertility Clinic Section 455, Hvidovre University Hospital, Kettegård Alle 30, Hvidovre, Copenhagen 2650, Denmark
| | - J Bogstad
- Department of Obstetrics & Gynaecology, Fertility Clinic Section 455, Hvidovre University Hospital, Kettegård Alle 30, Hvidovre, Copenhagen 2650, Denmark
| | - T Bryndorf
- Department of Obstetrics & Gynaecology, Fertility Clinic Section 455, Hvidovre University Hospital, Kettegård Alle 30, Hvidovre, Copenhagen 2650, Denmark
| | - K Løssl
- Department of Obstetrics & Gynaecology, Fertility Clinic Section 455, Hvidovre University Hospital, Kettegård Alle 30, Hvidovre, Copenhagen 2650, Denmark
| | - J Roskær
- Department of Obstetrics & Gynaecology, Fertility Clinic, Aalborg University Hospital, Dronninglund, Denmark
| | - T Holland
- Department of Obstetrics & Gynaecology, Fertility Clinic Section 455, Hvidovre University Hospital, Kettegård Alle 30, Hvidovre, Copenhagen 2650, Denmark
| | - L Prætorius
- Department of Obstetrics & Gynaecology, Fertility Clinic Section 455, Hvidovre University Hospital, Kettegård Alle 30, Hvidovre, Copenhagen 2650, Denmark
| | - A Zedeler
- Department of Obstetrics & Gynaecology, Fertility Clinic Section 455, Hvidovre University Hospital, Kettegård Alle 30, Hvidovre, Copenhagen 2650, Denmark
| | - L Nilas
- Department of Obstetrics & Gynaecology, Section of General Gynaecology, Hvidovre University Hospital, Hvidovre, Copenhagen, Denmark
| | - A Pinborg
- Department of Obstetrics & Gynaecology, Fertility Clinic Section 455, Hvidovre University Hospital, Kettegård Alle 30, Hvidovre, Copenhagen 2650, Denmark
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Blockeel C, Drakopoulos P, Santos-Ribeiro S, Polyzos NP, Tournaye H. A fresh look at the freeze-all protocol: a SWOT analysis. Hum Reprod 2016; 31:491-7. [PMID: 26724793 DOI: 10.1093/humrep/dev339] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 12/16/2015] [Indexed: 11/14/2022] Open
Abstract
The 'freeze-all' strategy with the segmentation of IVF treatment, namely with the use of a GnRH antagonist protocol, GnRH agonist triggering, the elective cryopreservation of all embryos by vitrification and a frozen-thawed embryo transfer in a subsequent cycle, has become more popular. However, the approach still encounters drawbacks. In this opinion paper, a SWOT (strengths, weaknesses, opportunities and threats) analysis sheds light on the different aspects of this strategy.
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Affiliation(s)
- Christophe Blockeel
- Centre for Reproductive Medicine, UZ Brussel, Laarbeeklaan 101, 1090 Jette, Belgium
| | | | | | - Nikolaos P Polyzos
- Centre for Reproductive Medicine, UZ Brussel, Laarbeeklaan 101, 1090 Jette, Belgium
| | - Herman Tournaye
- Centre for Reproductive Medicine, UZ Brussel, Laarbeeklaan 101, 1090 Jette, Belgium
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Nastri CO, Teixeira DM, Moroni RM, Leitão VMS, Martins WP. Ovarian hyperstimulation syndrome: pathophysiology, staging, prediction and prevention. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:377-93. [PMID: 25302750 DOI: 10.1002/uog.14684] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 09/25/2014] [Accepted: 09/29/2014] [Indexed: 05/25/2023]
Abstract
OBJECTIVE To identify, appraise and summarize the current evidence regarding the pathophysiology, staging, prediction and prevention of ovarian hyperstimulation syndrome (OHSS). METHODS Two comprehensive systematic reviews were carried out: one examined methods of predicting either high ovarian response or OHSS and the other examined interventions aimed at reducing the occurrence of OHSS. Additionally, we describe the related pathophysiology and staging criteria. RESULTS Seven studies examining methods of predicting OHSS and eight more examining methods of predicting high ovarian response to controlled ovarian stimulation were included. Current evidence shows that the best methods of predicting high response are antral follicle count and anti-Müllerian hormone levels, and that a high ovarian response (examined by the number of large follicles, estradiol concentration or the number of retrieved oocytes) is the best method of predicting the occurrence of OHSS. Ninety-seven randomized controlled trials examining the effect of several interventions for reducing the occurrence of OHSS were included. There was high-quality evidence that replacing human chorionic gonadotropin by gonadotropin-releasing hormone agonists or recombinant luteinizing hormone, and moderate-quality evidence that antagonist protocols, dopamine agonists and mild stimulation, reduce the occurrence of OHSS. The evidence for the effect of the other interventions was of low/very low quality. Additionally, we identified and described 12 different staging criteria. CONCLUSIONS There are useful predictive tools and several preventive interventions aimed at reducing the occurrence of OHSS. Acknowledging and understanding them are of crucial importance for planning the treatment of, and, ultimately, eliminating, OHSS while maintaining high pregnancy rates.
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Affiliation(s)
- C O Nastri
- Department of Obstetrics and Gynecology, Ribeirao Preto Medical School, University of Sao Paulo (DGO-FMRP-USP), Ribeirao Preto, Brazil; School of Health Technology - Ultrasonography School of Ribeirao Preto (FATESA-EURP), Ribeirao Preto, Brazil
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Klaffenbach D, Marx M, Herzog N, Völkl T, Dörr H. Gonadotropin-Releasing-Hormon-Agonisten-Therapie bei Pubertas praecox vera. Monatsschr Kinderheilkd 2014. [DOI: 10.1007/s00112-014-3255-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Luo S, Li S, Jin S, Li Y, Zhang Y. Effectiveness of GnRH antagonist in the management of subfertile couples undergoing controlled ovarian stimulation and intrauterine insemination: a meta-analysis. PLoS One 2014; 9:e109133. [PMID: 25299186 PMCID: PMC4192303 DOI: 10.1371/journal.pone.0109133] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 09/08/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Recent studies have indicated the use of gonadotropin-releasing hormone antagonists (GnRH-ant) as an adjuvant treatment to prevent premature luteinization (PL) and improve the clinical outcomes in patients undergoing controlled ovarian stimulation (COS) with intrauterine insemination (IUI). However, the results of these studies are conflicting. METHODS We conducted a systematic review and meta-analysis of randomized trials aiming to compare the clinical efficacy of GnRH-ant in COS/IUI cycles. Twelve studies were identified that met inclusion criteria and comprised 2,577 cycles assigned to COS/IUI combined GnRH-ant or COS/IUI alone. RESULTS Meta-analysis results suggested that GnRH-ant can significantly increase the clinical pregnancy rate (CPR) (OR = 1.42; 95% CI, 1.13-1.78) and decrease the PL rate (OR = 0.22, 95% CI, 0.16-0.30) in COS/IUI cycles. Subgroup analysis results suggested statistically significant improvement in the CPR in non-PCOS patients (OR = 1.54; 95% CI, 1.03-2.31) but not in the PCOS population (OR = 1.65; 95% CI, 0.93-2.94) and multiple mature follicle cycles (OR = 1.87; 95% CI, 0.27-12.66). There were no difference in the miscarriage and multiple pregnancy rates between the groups. CONCLUSION This meta-analysis suggested that GnRH-ant can reduce the incidence of PL and increase the CPR when used in COS/IUI cycles, and it was especially useful for non-PCOS patients. However, evidence to support its use in PCOS patients is still insufficient.
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Affiliation(s)
- Shan Luo
- Division of Reproductive Medical Center, West China Second University Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Shangwei Li
- Division of Reproductive Medical Center, West China Second University Hospital of Sichuan University, Chengdu, Sichuan, China
- * E-mail:
| | - Song Jin
- Division of Reproductive Medical Center, West China Second University Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Ya Li
- Division of Reproductive Medical Center, West China Second University Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yaoyao Zhang
- Division of Reproductive Medical Center, West China Second University Hospital of Sichuan University, Chengdu, Sichuan, China
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Xiao JS, Su CM, Zeng XT. Comparisons of GnRH antagonist versus GnRH agonist protocol in supposed normal ovarian responders undergoing IVF: a systematic review and meta-analysis. PLoS One 2014; 9:e106854. [PMID: 25216031 PMCID: PMC4162565 DOI: 10.1371/journal.pone.0106854] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 08/08/2014] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To evaluate the effectiveness and safety of GnRH antagonist and GnRH agonist in supposed normal ovarian responders undergoing IVF. METHODS Data from 6 databases were retrieved for this study. The RCTs of GnRH agonist and GnRH antagonist use during IVF-EF therapy for patients with supposed normal ovarian response were included. A meta-analysis was performed with Revman 5.1software. RESULTS Twenty-three RCTs met the inclusion criteria. The number of stimulation days (mean difference (MD): -0.66, 95% confidence interval (CI): -1.04∼-0.27), Gn amount (MD: -2.92, 95% CI: -5.0∼-0.85), E2 values on the day of HCG (MD: -330.39, 95% CI: -510.51∼-150.26), Number of oocytes retrieved (MD: -1.33, 95% CI: -2.02∼-0.64), clinical pregnancy rate (odds ratio (OR): 0.87, 95% CI: 0.75-1.0), and ovarian hyperstimulation syndrome (OHSS) incidence (OR: 0.59, 95% CI: 0.42∼0.82) were significantly lower in GnRH antagonist protocol than GnRH agonist protocol. However, the endometrial thickness on the day of HCG (MD: -0.04, 95% CI: -0.23∼0.14), the ongoing pregnancy rate (OR: 0.87, 95% CI: 0.74∼1.03), live birth rate (OR: 0.89, 95% CI: 0.64∼1.24), miscarriage rate (OR: 1.17, 95% CI: 0.85∼1.61), and cycle cancellation rate (OR: 1.11, 95% CI: 0.90∼1.37) did not significantly differ between the 2 groups. CONCLUSIONS During IVF treatment for patients with supposed normal responses, the incidence of OHSS were significantly lower, whereas the ongoing pregnancy and live birth rates were similar in the GnRH antagonist compared with the standard long GnRH agonist protocols.
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Affiliation(s)
- Jin-song Xiao
- Reproductive Medicine Center, Taihe Hospital, Hubei University of medicine, Shiyan City, Hubei Province, China
| | - Cun-mei Su
- Reproduction Medicine and Treatment Center of Yunnan Province Population and Family Planning Science and Technology Institute, No. 150, Wuhua District, Kunming, Yunnan, China
| | - Xian-tao Zeng
- Evidence-Based Medicine Center of Hubei Medical College Affiliated Taihe Hospital, Shiyan City, HuBei, China
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Chen Y, Zhang Y, Hu M, Liu X, Qi H. Timing of human chorionic gonadotropin (hCG) hormone administration in IVF/ICSI protocols using GnRH agonist or antagonists: a systematic review and meta-analysis. Gynecol Endocrinol 2014; 30:431-7. [PMID: 24731070 DOI: 10.3109/09513590.2014.895984] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To evaluate the effect of altering the timing of human chorionic gonadotropin (hCG) administration on the clinical outcome of in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) using gonadotropic hormone releasing hormone (GnRH) agonist or antagonist. METHODS We systematically searched six databases. Randomized controlled trials (RCTs) of the effects of altering the timing of hCG administration on the clinical outcome of IVF and ICSI using GnRH agonist or antagonist were included. A meta-analysis was conducted following a quality evaluation performed with Cochrane Collaboration's Review Manager (RevMan) 5.0.2. RESULTS Seven RCTs and a total of 1295 participants were included. Significant difference was observed regarding estradiol and progesterone levels on the day of hCG administration and oocyte retrieval between early hCG and late hCG administration group and in favor of the latter. The fertilization rate was not statistically different between early and 24-h late hCG groups, but it is significantly higher in the 48-h late hCG group. The pooled results showed no significant differences in the ongoing pregnancy rate per oocyte pick-up, the miscarriage rate and the live birth rate. CONCLUSION The prolongation of follicular phase by delaying hCG administration could increase estradiol, progesterone levels and oocyte retrieval, which will not influence ongoing pregnancy rate per oocyte pick-up, miscarriage rate and live birth rate. Postponing hCG may enable increased flexibility of cycle scheduling to avoid weekend procedures.
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Affiliation(s)
- Ying Chen
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University , Chongqing , P.R. China and
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La Marca A, D’Ippolito G. Ovarian response markers lead to appropriate and effective use of corifollitropin alpha in assisted reproduction. Reprod Biomed Online 2014; 28:183-90. [DOI: 10.1016/j.rbmo.2013.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Revised: 10/12/2013] [Accepted: 10/15/2013] [Indexed: 10/26/2022]
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Progesterone elevation does not compromise pregnancy rates in high responders: a pooled analysis of in vitro fertilization patients treated with recombinant follicle-stimulating hormone/gonadotropin-releasing hormone antagonist in six trials. Fertil Steril 2013; 100:1622-8.e1-3. [DOI: 10.1016/j.fertnstert.2013.08.045] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 08/02/2013] [Accepted: 08/27/2013] [Indexed: 11/21/2022]
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Frattarelli JL, Hillensjö T, Broekmans FJ, Witjes H, Elbers J, Gordon K, Mannaerts B. Clinical impact of LH rises prior to and during ganirelix treatment started on day 5 or on day 6 of ovarian stimulation. Reprod Biol Endocrinol 2013; 11:90. [PMID: 24028076 PMCID: PMC3847921 DOI: 10.1186/1477-7827-11-90] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 09/01/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We sought to evaluate the incidence and clinical impact of luteinizing hormone (LH) rises prior to and during gonadotropin-releasing hormone (GnRH) antagonist treatment started on day 5 or 6 of ovarian stimulation with recombinant follicle-stimulating hormone (rFSH). METHODS Pooled data from three trials with the GnRH antagonist ganirelix started on day 5 (n = 961) and from five trials with ganirelix started on day 6 (n = 1135) of ovarian stimulation with rFSH were retrospectively analyzed. RESULTS The incidence of LH rises (LH ≥ 10.0 IU/L) prior to ganirelix treatment was 2.3% and 6.6% on ganirelix start days 5 and 6, respectively (P < 0.01). During ganirelix treatment this incidence was 1.2% and 2.3%, respectively (P = 0.06). Women with LH rise on day 5 or 6 had a higher ovarian response with more oocytes recovered, mean ± SD, 12.9 ± 8.5 versus no LH rise, 10.2 ± 6.4 (P < 0.01). In women with and without LH rise prior to ganirelix treatment the ongoing pregnancy rates were similar (26.0% vs 29.9%; odds ratio [OR], 0.89; 95% confidence interval [CI], 0.55-1.44). Women with LH rise during ganirelix treatment had a lower ovarian response with 7.5 ± 6.7 oocytes recovered versus no LH rise, 10.2 ± 6.4 (P = 0.02) and a tendancy for a lower chance of ongoing pregnancy (16.7% vs 29.9%; OR, 0.52; 95% CI, 0.21-1.26). CONCLUSIONS The incidence of early and late LH rises was low but may be further reduced by initiating ganirelix on stimulation day 5 rather than on day 6. In contrast to women with an early LH rise, women with a late LH rise may have a reduced chance of ongoing pregnancy.
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Affiliation(s)
- John L Frattarelli
- Advanced Reproductive Medicine & Gynecology of Hawaii, Inc., 1401 South Beretania St, Honolulu, Hawaii 96814, USA
| | | | - Frank J Broekmans
- Department of Reproductive Medicine, University Medical Center Utrecht, Utrecht, Netherlands
| | | | | | - Keith Gordon
- Merck Sharp & Dohme Corp., Whitehouse Station, NJ, USA
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Weissman A, Ravhon A, Steinfeld Z, Nahum H, Golan A, Levran D. Controlled ovarian stimulation using a long gonadotropin-releasing hormone antagonist protocol: a proof of concept and feasibility study. Gynecol Obstet Invest 2013; 76:113-8. [PMID: 23920048 DOI: 10.1159/000351570] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 04/23/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS To evaluate the feasibility of a long protocol of controlled ovarian stimulation prior to in vitro fertilization (IVF) and embryo transfer with a gonadotropin-releasing hormone (GnRH) antagonist used for pituitary and ovarian suppression. METHODS Thirty patients undergoing IVF/intracytoplasmic sperm injection were randomized into two groups. The control group (n = 16) received a standard flexible GnRH antagonist protocol. Ovarian stimulation consisted of 225 IU/day of recombinant follicle-stimulating hormone for 5 days, followed by 225 IU/day of human menopausal gonadotropin until human chorionic gonadotropin (hCG) administration. The study group (n = 14) received 0.25 mg of GnRH antagonist daily for 7 days, thereafter, upon confirmation of pituitary and ovarian suppression, ovarian stimulation was commenced with the same protocol as used in the control group. Hormone and follicle dynamics, as well as laboratory characteristics and cycle outcome, were compared for both groups. RESULTS Both groups were comparable in baseline characteristics. Pituitary and ovarian suppression were effectively achieved in 12/14 patients in the study group. The duration of ovarian stimulation and gonadotropin consumption were similar in both groups, as was also the number and size of follicles on hCG day. CONCLUSION The results of our study confirm the feasibility of a long GnRH antagonist protocol. This regimen could become another option to optimize GnRH antagonist protocols, and should thus be further explored.
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Affiliation(s)
- Ariel Weissman
- IVF Unit, Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Ludwig M, Katalinic A, Felberbaum RE, Diedrich K. Safety aspects of gonadotrophin-releasing hormone antagonists in ovarian stimulation procedures: ovarian hyperstimulation syndrome and health of children born. Reprod Biomed Online 2013; 5 Suppl 1:61-7. [PMID: 12537784 DOI: 10.1016/s1472-6483(11)60219-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The safety of ovarian stimulation procedures or the procedure of assisted reproduction in general can be estimated by various parameters. Two of the most important are the health of children born after the procedure and the incidence of ovarian hyperstimulation syndrome (OHSS). The latter is important because it is the most severe, potentially life-threatening complication of any stimulation procedure. The use of gonadotrophin-releasing hormone (GnRH) antagonists in ovarian stimulation protocols has had no impact on the health of children born. This was proven in 227 children born after the use of cetrorelix and in 73 children born after the use of ganirelix. To analyse the incidence of OHSS and the impact of GnRH antagonists on clinical pregnancy rates compared with the long protocol, a meta-analysis was done. This showed a reduction of OHSS with the use of cetrorelix. Furthermore, when compared with the long protocol, clinical and ongoing pregnancy rates were not significantly reduced with the use of cetrorelix. Taken together, the use of GnRH antagonists are safe with regard to children's health. The incidence of OHSS does not increase with ganirelix, and a reduction can be expected with cetrorelix.
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Affiliation(s)
- M Ludwig
- Division of Reproductive Medicine and Gynecologic Endocrinology, Department of Gynecology and Obstetrics, University Clinic, Ratzeburger Allee 160, 23538 Lübeck, Germany.
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Barri PN, Martinez F, Coroleu B, Tur R. The role of GnRH antagonists in assisted reproduction. Reprod Biomed Online 2013; 5 Suppl 1:14-9. [PMID: 12537777 DOI: 10.1016/s1472-6483(11)60212-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The different schemes of application of gonadotrophin-releasing hormone (GnRH) antagonists in ovarian stimulation protocols for assisted reproduction are reviewed. Starting from the initial schemes of single and/or multiple doses, the efficacy of GnRH antagonists in 'soft' protocols of ovarian stimulation has been evaluated in natural cycles, and the possibility of inducing the final oocyte maturation under antagonists either with native luteinizing hormone-releasing hormone or with GnRH agonists. The largest clinical studies carried out with cetrorelix or with ganirelix and published to date were analysed. Apart from the benefits of reducing the duration of the treatment, gonadotrophin requirements and ovarian hyperstimulation syndrome incidence, there is still a serious debate on the potential deleterious effect of GnRH antagonists on implantation and pregnancy rates. More specific aspects such as cycle programming, application of GnRH antagonists in protocols for poor responders etc., were also reviewed in this survey.
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Affiliation(s)
- Pedro N Barri
- Service of Reproductive Medicine, Department of Obstetrics and Gynecology, Institut Universitari Dexeus, Paseo Bonanova 67, 08017 Barcelona, Spain.
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Olivennes F. GnRH antagonists: do they open new pathways to safer treatment in assisted reproductive techniques? Reprod Biomed Online 2013; 5 Suppl 1:20-5. [PMID: 12537778 DOI: 10.1016/s1472-6483(11)60213-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
GnRH antagonists (GnRHnt) induce a rapid decrease in LH and FSH, preventing and interrupting LH surges. Their properties do not require a desensitization period and allow their use in the late follicular phase. GnRHnt could replace GnRH agonists (GnRHa) in ovarian stimulation without their side-effects and their long period of desensitivity. Both protocols using GnRHnt were associated with a smaller amount of gonadotrophin, a shorter stimulation period and a lower incidence of ovarian hyperstimulation syndrome (OHSS) with statistically comparable pregnancy rates. There is room for improvement of both protocols concerning the programming, the antagonist dose and the timing of antagonist administration. Luteal support should be maintained until the results of further studies. The perinatal outcome appears to be similar to that of other stimulation regimens. Triggering of ovulation can be facilitated by GnRHa for patients at risk of OHSS. Provided that pregnancy rates equivalent to those obtained with GnRHa are confirmed in larger series, GnRHnt will clearly represent a safer alternative to GnRHa protocols in IVF.
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Affiliation(s)
- F Olivennes
- Department of Obstetrics and Gynecology II, Unit of Reproductive Medicine, Hôpital Cochin, 123 Boulevard de Port Royal, 75014 Paris, France
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Early initiation of gonadotropin-releasing hormone antagonist treatment results in a more stable endocrine milieu during the mid- and late-follicular phases: a randomized controlled trial comparing gonadotropin-releasing hormone antagonist initiation on cycle day 2 or 6. Fertil Steril 2013; 100:867-74. [PMID: 23809501 DOI: 10.1016/j.fertnstert.2013.05.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Revised: 05/20/2013] [Accepted: 05/21/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To compare the effect of initiating GnRH antagonist (GnRH-a) on cycle day (CD) 2 vs. CD 6 on LH, E₂, and P levels in the mid and late follicular phases. DESIGN Nested study within a multicenter randomized controlled trial. SETTING Reproductive medicine center in an university hospital. PATIENT(S) One hundred sixty patients undergoing IVF/intracytoplasmic sperm injection (ICSI). INTERVENTION(S) Recombinant FSH (150-225 IU) was administered daily from CD 2 onward. The study group (CD 2) started GnRH-a cotreatment on CD 2, whereas the control group (CD 6) started on CD 6. MAIN OUTCOME MEASURE(S) The follicular phase endocrine profile. RESULT(S) The LH levels on CD 6 were lower in the CD 2 group (0.6 ± 0.4 vs. 1.9 ± 1.4 IU/L). The CD 2 group demonstrated both lower E₂ levels on CD 6 (520.1 ± 429.6 pmol/L vs. 1,071.7 ± 654.2 pmol/L) and on the day of hCG administration (3,341.4 ± 1,535.3 pmol/L vs. 4,573.2 ± 2,445.4 pmol/L). The P levels did not differ on CD 6 or on the day of hCG administration. CONCLUSION(S) Early initiation of GnRH-a cotreatment results in a more stable endocrine profile, with more physiological levels of E2 and LH during the follicular phase. The effect on clinical outcomes must be established in larger trials. CLINICAL TRIAL REGISTRATION NUMBER NCT00866034.
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Copperman AB, Benadiva C. Optimal usage of the GnRH antagonists: a review of the literature. Reprod Biol Endocrinol 2013; 11:20. [PMID: 23496864 PMCID: PMC3618003 DOI: 10.1186/1477-7827-11-20] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 02/27/2013] [Indexed: 11/25/2022] Open
Abstract
Gonadotropin-releasing hormone (GnRH) antagonists, which became commercially available from 1999, have been used for the prevention of premature luteinizing hormone (LH) surges in controlled ovarian stimulation for in vitro fertilization or intracytoplasmic sperm injection. This review focuses on the recent literature on the use of GnRH antagonists and provides guidelines for optimal use in light of increasing evidence showing that GnRH antagonists are safe and effective, allowing flexibility of treatment in a wide range of patient populations. This includes patients undergoing first-line controlled ovarian stimulation, poor responders, and women diagnosed with polycystic ovary syndrome. The GnRH antagonist offers a viable alternative to the long agonists, providing a shorter duration of treatment with fewer injections and with no adverse effects on assisted reproductive technology outcome. This results in a significantly lower amount of gonadotropins required, which is likely to lead to improved patient compliance.
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Affiliation(s)
- Alan B Copperman
- Mount Sinai Medical Center, New York, NY, USA
- Reproductive Medicine Associates of New York, New York, NY, USA
| | - Claudio Benadiva
- The Center for Advanced Reproductive Services, Department of Ob/Gyn, University of Connecticut, Farmington, CT, USA
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Tannus S, Weissman A, Boaz M, Horowitz E, Ravhon A, Golan A, Levran D. The effect of delayed initiation of gonadotropin-releasing hormone antagonist in a flexible protocol on in vitro fertilization outcome. Fertil Steril 2013; 99:725-30. [DOI: 10.1016/j.fertnstert.2012.11.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 11/08/2012] [Accepted: 11/08/2012] [Indexed: 10/27/2022]
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Marci R, Caserta D, Lisi F, Graziano A, Soave I, Lo Monte G, Patella A, Moscarini M. In vitro fertilization stimulation protocol for normal responder patients. Gynecol Endocrinol 2013; 29:109-12. [PMID: 22943624 DOI: 10.3109/09513590.2012.712002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The aim of this prospective observational study is to determine the different outcomes of IVF/ICSI treatments after using antagonists or agonists of gonadotrophin-releasing hormone (GnRH) for controlled ovarian hyperstimulation (COH) in normal responder patients. Two hundred forty-seven patients undergoing IVF treatment at the Centre of Reproductive Medicine, Rome (CERMER), from January 2005 to December 2008, were included in the study. Patients were stimulated either with a standard long protocol with GnRH agonists (n = 156) or with GnRH antagonists (n = 91). The use of GnRH antagonists resulted in a significant reduction in the duration of the stimulation (Agonist Group 14.10 ± 2.25 vs Antagonist Group 11.34 ± 2.11; p < 0.001) and in the amount of gonadotrophin (IU of r-FSH) needed (Agonist Group 1878 ± 1109 vs Antagonist Group 1331 ± 1049; p = 0.0014). Moreover a lower number of cycles were cancelled with the antagonist protocol (4.39 vs 6.41%). The GnRH antagonist protocol, when compared to the GnRH agonist one, is associated with a similar clinical pregnancy rate, similar implantation rate, significantly lower gonadotrophin requirement and shorter duration of stimulation. For this reason, GnRH antagonists might be a good treatment even for normal responder patients undergoing IVF.
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Affiliation(s)
- R Marci
- Department of Biomedical Sciences and Advanced Therapies, University of Ferrara, Ferrara, Italy.
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Liu N, Ma Y, Li R, Jin H, Li M, Huang X, Feng HL, Qiao J. Comparison of follicular fluid amphiregulin and EGF concentrations in patients undergoing IVF with different stimulation protocols. Endocrine 2012; 42:708-16. [PMID: 22678853 DOI: 10.1007/s12020-012-9706-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 05/14/2012] [Indexed: 01/22/2023]
Abstract
Epidermal growth factor (EGF)-like growth factors, such as amphiregulin (AR) and EGF, have emerged as mediators to propagate Luteinizing hormone (LH) stimulus for the oocyte maturation throughout the preovulatory follicle, because cumulus cells and oocytes express few or no LH receptors. This study was to compare AR and EGF concentrations in follicular fluid (FF) among four controlled ovary stimulation (COS) protocols and to investigate the relationship between FF EGF-like growth factors and COS outcomes. Ninety-five patients who underwent in vitro fertilization-embryo transfer (IVF-ET) were treated by four different COS protocols, including gonadotropin-releasing hormone agonist (GnRH-a) long protocol, GnRH-a ultra-long protocol, GnRH-a short protocol, and GnRH antagonist protocol. FF was taken on oocyte retrieval day. FF AR and EGF concentrations were measured and their correlations with COS outcomes were analyzed. FF AR concentration was significantly different from each other among four COS protocol groups (GnRH-a ultra-long protocol group, 186.12 ng/ml; GnRH-a long protocol group, 128.35 ng/ml; GnRH antagonist protocol group, 108.23 ng/ml; GnRH-a short protocol group, 77.13 ng/ml, p < 0.05). FF AR concentrations were higher in GnRH-a ultra-long and long protocol groups, while number of oocytes retrieval, available embryos, and good quality embryos in these two groups were also significantly higher than GnRH-a short protocol group and GnRH antagonist protocol group. FF AR concentration was positively correlated with available embryos, but negatively correlated with serum LH level on hCG day. FF EGF concentration had no relationship with COS parameters. Different COS protocols might have variable effects on AR synthesis. FF AR might be a good indicator to predict the number of oocytes and embryos. FF AR elevation may result in increasing the number of oocyte retrieval and embryo generation, consequently increased cumulative pregnancy rate.
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Affiliation(s)
- Nana Liu
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, No. 49, Huayuan North Road, Haidian District, Beijing, 100191, China
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Orvieto R, Patrizio P. GnRH agonist versus GnRH antagonist in ovarian stimulation: an ongoing debate. Reprod Biomed Online 2012. [PMID: 23186555 DOI: 10.1016/j.rbmo.2012.11.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The availability of gonadotrophin-releasing hormone (GnRH) antagonists for ovarian stimulation protocols has generated many meta-analyses comparing it to GnRH agonist long protocols. These meta-analyses have yielded conflicting results for pregnancy rate, with a tendency toward a better outcome for GnRH agonists. Recently, a Cochrane review seems to have settled the conflicts by demonstrating no evidence of statistically significant differences in the rates of live births or ongoing pregnancies when comparing GnRH agonist long protocols with GnRH antagonist protocols. This paper disputes the equivalence of these two protocols as discussed in the latest meta-analysis and argue that the GnRH agonist still has a demonstrable superiority over GnRH antagonist protocols. The availability of gonadotrophin-releasing hormone (GnRH) antagonist for ovarian stimulation protocols has generated many meta-analyses comparing it to GnRH agonist long protocols. These meta-analyses have yielded conflicting results for pregnancy rate, with a tendency towards a better outcome for GnRH agonists. Recently, a Cochrane review seems to have settled the conflicts by demonstrating no evidence of statistically significant differences in the rates of live births or ongoing pregnancies when comparing GnRH agonist long protocols with GnRH antagonist protocols. In this paper, we dispute the equivalence of these two protocols as discussed in the latest meta-analysis and argue that the GnRH agonist still has a demonstrable superiority over GnRH antagonist protocols.
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Affiliation(s)
- Raoul Orvieto
- Department of Obstetrics and Gynecology, Barzilai Medical Center, Ashkelon, Israel.
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Qiao J, Lu G, Zhang HW, Chen H, Ma C, Olofsson JI, Witjes H, Heijnen E, Mannaerts B. A randomized controlled trial of the GnRH antagonist ganirelix in Chinese normal responders: high efficacy and pregnancy rates. Gynecol Endocrinol 2012; 28:800-4. [PMID: 22429192 DOI: 10.3109/09513590.2012.665103] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Gonadotropin-releasing hormone (GnRH) antagonists for controlled ovarian stimulation (COS) were only recently introduced into China. The efficacy and safety of the GnRH antagonist ganirelix was assessed in a multicenter, controlled, open-label study, in which Chinese women were randomized to either ganirelix (n = 113) or a long GnRH agonist protocol of triptorelin (n = 120). The primary end point was the amount of recombinant follicle-stimulating hormone (rFSH) required to meet the human chorionic gonadotropin criterion (three follicles ≥17 mm). The amount of rFSH needed was significantly lower for ganirelix (1272 IU) vs. triptorelin (1416 IU; P< 0.001). Ongoing pregnancy rates per started cycle were 39.8% (ganirelix) and 39.2% (triptorelin). Although both treatments were well tolerated, cancellation due to risk of ovarian hyperstimulation syndrome (OHSS) was less frequent with ganirelix (1.8%) than triptorelin (7.5%) (P = 0.06). Less rFSH was needed in the ganirelix protocol than the long GnRH agonist protocol, with fewer reported cases of OHSS and similar pregnancy rates.
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Affiliation(s)
- Jie Qiao
- Reproductive Medical Center, Peking University Third Hospital, Beijing, China
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