Effect of unplanned spontaneous follicular growth and ovulation on pregnancy outcomes in planned artificial frozen embryo transfer cycles: a propensity score matching study

Establishment and validation of a nomogram model for predicting ovulation in the PCOS women

BACKGROUND

The mechanisms underlying ovulatory dysfunction in PCOS remain debatable. This study aimed to identify the factors affecting ovulation among PCOS patients based on a large sample-sized randomized control trial.

METHODS

Data were obtained from a multi-centered randomized clinical trial, the PCOSAct, which was conducted between 2011 and 2015. Univariate and multivariate analysis using binary logistic regression were used to construct a prediction model and nomogram. The accuracy of the model was assessed using receiver operating characteristic (ROC) curves and calibration curves.

RESULTS

The predictive variables included in the training dataset model were luteinizing hormone (LH), free testosterone, body mass index (BMI), period times per year, and clomiphene treatment. The ROC curve for the model in the training dataset was 0.81 (95% CI [0.77, 0.85]), while in the validation dataset, it was 0.7801 (95% CI [0.72, 0.84]). The model showed good discrimination in both the training and validation datasets. Decision curve analysis demonstrated that the nomogram designed for ovulation had clinical utility and superior discriminative ability for predicting ovulation.

CONCLUSIONS

The nomogram composed of LH, free testosterone, BMI, period times per year and the application of clomiphene may predict the ovulation among PCOS patients.

Serum LH level prior to progestin administration is significant on pregnancy and live birth in programmed frozen-thawed embryo transfer cycles

Purpose

To evaluate the impact of serum LH levels prior to progestin administration on the outcomes of programmed frozen-thawed embryo transfer (FET) cycles.

Methods

Retrospective cohort study was conducted to compare the treatment outcomes between four groups based on the 25 percentiles of serum LH levels before progestin administration in 596 cycles of 518 patients undergoing artificial endometrial preparation protocols for FET. Primary outcome measures were ongoing and live birth rates. Secondary outcome measures were the pregnancy rates, clinical pregnancy rates, and pregnancy loss rates.

Results

The trends in clinical pregnancy (CPR) and live birth rates (LBR) increased from the first to the fourth quartile (Q1 to Q4) of serum LH levels prior to progestin administration (37,0% to 48,3%, p = 0.042, and 22.6% to 39.5%, respectively, p = 0.003). Pregnancy loss rates (PLR) were higher in group Q1, although the difference was not statistically significant. Based on a multivariate logistic regression analysis, a low serum LH level before progestin initiation was found to be the most significant predictor associated with a negative effect on live birth (OR: 0,421, 95% CI 0,178 - 0,994, p=0,048). The day of estrogen initiation was significantly correlated with serum LH levels and quartiles of serum LH levels before progestin administration (r=0,200, p=0,015 and r=0,215, p=0,009, respectively).

Conclusion

The serum LH level prior to progestin administration significantly affects pregnancy and live birth rates in patients undergoing an artificial endometrial preparation protocol for FET. LH monitoring should be incorporated into the follow-up, in addition to assessing endometrial thickness and morphology in artificial FET cycles.

The effects of unexpected follicular growth and ovulation in artificial cycles: a retrospective cohort study of frozen, single-blastocyst transfer

OBJECTIVE

To study the effects of unexpected follicular development and ovulation in artificial cycles (ACs) on pregnancy outcomes.

DESIGN

A retrospective cohort study.

SETTING

A university-affiliated fertility center.

PATIENT(S)

A total of 1,427 patients who underwent a single, frozen-thawed blastocyst transfer with AC regimens from January 2014 to December 2020 at a university-affiliated fertility center were included.

INTERVENTION(S)

Unexpected follicular development and ovulation in ACs.

MAIN OUTCOME MEASURE(S)

Live birth rate (LBR), biochemical pregnancy rate, clinical pregnancy rate, and ongoing pregnancy rate.

RESULT(S)

A total of 161 patients with unexpected follicular development and ovulation in ACs (ovulation group) and 1,266 patients without growing follicles in ACs (control group) were enrolled. The patients in the ovulation group were older and had higher levels of serum follicle-stimulating hormone and lower levels of serum antimüllerian hormone. After propensity score matching, the baseline characteristics between the 2 groups were comparable and no significant difference was observed in the LBR (ovulation group, 39.0% vs. control group, 39.0%), biochemical pregnancy rate (ovulation group, 60.3% vs. control group, 58.2%), clinical pregnancy rate (ovulation group, 53.4% vs. control group, 50.7%), or ongoing pregnancy rate (ovulation group, 42.5% vs. control group, 40.4%). Moreover, the patients in the ovulation group showed a lower risk of hypertensive disorders of pregnancy (HDP) (1.6% vs. 15.3%). A subgroup analysis of women who delivered singleton live-born babies also demonstrated that unexpected follicular development and ovulation in ACs was associated with a decreased risk of HDP (adjusted odds ratio, 0.070; 95% confidence interval, 0.007-0.712) and an increased risk of large-for-gestational-age infants (adjusted odds ratio, 4.046; 95% confidence interval, 1.319-12.414).

CONCLUSION(S)

Women with unexpected follicular development and ovulation during single frozen-thawed blastocyst transfer with AC regimens had a similar LBR and a reduced risk of HDP compared with those with routine AC regimens, and singleton neonates had an increased risk of being large for gestational age.

Effect of elevated progesterone levels the day before ovulation on pregnancy outcomes in natural cycles of frozen thawed embryo transfer

OBJECTIVE

We aimed to analyze whether elevated progesterone levels on the day before ovulation affected pregnancy outcomes in natural cycles of frozen thawed embryo transfer (NC-FET).

METHODS

A retrospective analysis was conducted in a public university hospital. Data on clinical pregnancy, live birth, ectopic pregnancy, and miscarriage rates were collected, along with other patient data. Patients were divided into two groups according to their progesterone levels the day before ovulation: the progesterone elevation (PE) group (progesterone level >1.0 ng/mL) and the normal progesterone (NP) group (progesterone level ≤1.0 ng/mL). We assessed the effect of elevated progesterone levels in NC-FET by performing multivariate logistic regression analysis.

RESULTS

Overall 1159 women with tubal factor infertility who underwent NC-FET were enrolled, including 666 women who received cleavage-stage embryo transfers and 493 women who received blastocyst embryo transfers. When two cleavage-stage embryos were transferred, the clinical pregnancy rate was significantly higher in the PE than in the NP group following NC-FET (p < .05). After correcting for various confounders, we found that elevated progesterone levels (adjusted odds ratio [OR]: 1.672; 95% confidence interval [CI]: 1.089-2.566, p = .018) improved the clinical pregnancy rate following transfer of two cleavage-stage embryos but did not affect the pregnancy rate when blastocyst-stage embryos were transferred (adjusted OR: 0.856; 95% CI: 0.536-1.369; p = .517).

CONCLUSIONS

The results showed that in patients undergoing cleavage-stage NC-FET, progesterone levels >1.0 ng/mL improved the clinical pregnancy rates. However, the level of progesterone had no effect on the clinical pregnancy rate for patients undergoing blastocyst-stage NC-FET.

Functional Ovarian Cysts in Artificial Frozen-Thawed Embryo Transfer Cycles With Depot Gonadotropin-Releasing Hormone Agonist

OBJECTIVES

To investigate the incidence of functional ovarian cysts, its influence on clinical rates, and proper management after depot gonadotropin-releasing hormone (GnRH) agonist pretreatment in artificial frozen-thawed embryo transfer cycles (AC-FET).

METHODS

This retrospective cohort study involved 3375 AC-FET cycles with follicular-phase depot GnRH agonist administration between January 2017 and December 2020. Subjects were divided into a study group (cycles with cyst formation) and a control group (cycles without cyst formation). The study group was matched by propensity scoring matching with the control group at a ratio of 1:2. For patients with ovarian cyst formation, two major managements were used: a conservative approach (i.e., expectant treatment) and a drug approach (i.e., continued agonist administration). The primary outcome was live birth rate (LBR).

RESULTS

The incidence of functional ovarian cysts following pituitary downregulation is 10.1% (341/3375). The study group exhibited a LBR similar to the control group (54.5% vs. 50.1%, adjusted odds ratio [aOR] 1.17, 95% confidence interval [CI] 0.88-1.56, P = 0.274). Patients with a lower body mass index and anti-Müllerian hormone, and a higher basal estradiol level were more susceptible to developing functional ovarian cysts. The LBR decreased after the drug approach compared with the conservative approach, but not significantly (aOR 0.63, 95% CI 0.35-1.14, P = 0.125). Following the conservative approach, cycles arrived at live births had a significantly shorter duration from the detection of functional cysts to the start of endometrium preparation (15.7 ± 5.1 days vs. 17.4 ± 5.3 days, P = 0.009) and a significantly higher proportion of ovarian cysts on the initial day of exogenous hormone supplementation (51.4% vs. 30.3%, P = 0.001). After controlling for all confounders, the differences remained statistically significant.

CONCLUSIONS

It is unnecessary to cancel cycles that experience functional ovarian cyst formation. Conservative management and further agonist suppression protocol had similar pregnancy rates. However, a conservative approach was recommended due to its lower cost and fewer side effects. Our findings support a shorter waiting period when choosing the conservative protocol.