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Raperport C, Desai J, Qureshi D, Rustin E, Balaji A, Chronopoulou E, Homburg R, Khan KS, Bhide P. The definition of unexplained infertility: A systematic review. BJOG 2023. [PMID: 37957032 DOI: 10.1111/1471-0528.17697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 09/21/2023] [Accepted: 10/15/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND There is no consensus on tests required to either diagnose unexplained infertility or use for research inclusion criteria. This leads to heterogeneity and bias affecting meta-analysis and best practice advice. OBJECTIVES This systematic review analyses the variability of inclusion criteria applied to couples with unexplained infertility. We propose standardised criteria for use both in future research studies and clinical diagnosis. SEARCH STRATEGY CINAHL and MEDLINE online databases were searched up to November 2022 for all published studies recruiting couples with unexplained infertility, available in full text in the English language. DATA COLLECTION AND ANALYSIS Data were collected in an Excel spreadsheet. Results were analysed per category and methodology or reference range. MAIN RESULTS Of 375 relevant studies, only 258 defined their inclusion criteria. The most commonly applied inclusion criteria were semen analysis, tubal patency and assessment of ovulation in 220 (85%), 232 (90%), 205 (79.5%) respectively. Only 87/220 (39.5%) studies reporting semen analysis used the World Health Organization (WHO) limits. Tubal patency was accepted if bilateral in 145/232 (62.5%) and if unilateral in 24/232 (10.3%). Ovulation was assessed using mid-luteal serum progesterone in 115/205 (56.1%) and by a history of regular cycles in 87/205 (42.4%). Other criteria, including uterine cavity assessment and hormone profile, were applied in less than 50% of included studies. CONCLUSIONS This review highlights the heterogeneity among studied populations with unexplained infertility. Development and application of internationally accepted criteria will improve the quality of research and future clinical care.
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Affiliation(s)
- Claudia Raperport
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Jessica Desai
- Queen Mary University of London Medical School, London, UK
| | | | | | - Aparna Balaji
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
- North West Anglia NHS Foundation Trust, Peterborough, UK
| | | | - Roy Homburg
- Hewitt Fertility Centre, Liverpool Women's Hospital, Liverpool, UK
| | - Khalid Saeed Khan
- Department of Preventative Medicine and Public Health, Faculty of Medicine, University of Granada, Granada, Spain
- CIBER Epidemiology and Public Health, Madrid, Spain
| | - Priya Bhide
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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Cantineau AE, Rutten AG, Cohlen BJ. Agents for ovarian stimulation for intrauterine insemination (IUI) in ovulatory women with infertility. Cochrane Database Syst Rev 2021; 11:CD005356. [PMID: 34739136 PMCID: PMC8570324 DOI: 10.1002/14651858.cd005356.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Intrauterine insemination (IUI), combined with ovarian stimulation (OS), has been demonstrated to be an effective treatment for infertile couples. Several agents for ovarian stimulation, combined with IUI, have been proposed, but it is still not clear which agents for stimulation are the most effective. This is an update of the review, first published in 2007. OBJECTIVES To assess the effects of agents for ovarian stimulation for intrauterine insemination in infertile ovulatory women. SEARCH METHODS We searched the Cochrane Gynaecology and Fertility Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and two trial registers from their inception to November 2020. We performed reference checking and contacted study authors and experts in the field to identify additional studies. SELECTION CRITERIA We included truly randomised controlled trials (RCTs) that compared different agents for ovarian stimulation combined with IUI for infertile ovulatory women concerning couples with unexplained infertility. mild male factor infertility and minimal to mild endometriosis. DATA COLLECTION AND ANALYSIS We used standard methodological procedures recommended by Cochrane. MAIN RESULTS In this updated review, we have included a total of 82 studies, involving 12,614 women. Due to the multitude of comparisons between different agents for ovarian stimulation, we highlight the seven most often reported here. Gonadotropins versus anti-oestrogens (13 studies) For live birth, the results of five studies were pooled and showed a probable improvement in the cumulative live birth rate for gonadotropins compared to anti-oestrogens (odds ratio (OR) 1.37, 95% confidence interval (CI) 1.05 to 1.79; I2 = 30%; 5 studies, 1924 participants; moderate-certainty evidence). This suggests that if the chance of live birth following anti-oestrogens is assumed to be 22.8%, the chance following gonadotropins would be between 23.7% and 34.6%. The pooled effect of seven studies revealed that we are uncertain whether gonadotropins lead to a higher multiple pregnancy rate compared with anti-oestrogens (OR 1.58, 95% CI 0.60 to 4.17; I2 = 58%; 7 studies, 2139 participants; low-certainty evidence). Aromatase inhibitors versus anti-oestrogens (8 studies) One study reported live birth rates for this comparison. We are uncertain whether aromatase inhibitors improve live birth rate compared with anti-oestrogens (OR 0.75, CI 95% 0.51 to 1.11; 1 study, 599 participants; low-certainty evidence). This suggests that if the chance of live birth following anti-oestrogens is 23.4%, the chance following aromatase inhibitors would be between 13.5% and 25.3%. The results of pooling four studies revealed that we are uncertain whether aromatase inhibitors compared with anti-oestrogens lead to a higher multiple pregnancy rate (OR 1.28, CI 95% 0.61 to 2.68; I2 = 0%; 4 studies, 1000 participants; low-certainty evidence). Gonadotropins with GnRH (gonadotropin-releasing hormone) agonist versus gonadotropins alone (4 studies) No data were available for live birth. The pooled effect of two studies revealed that we are uncertain whether gonadotropins with GnRH agonist lead to a higher multiple pregnancy rate compared to gonadotropins alone (OR 2.53, 95% CI 0.82 to 7.86; I2 = 0; 2 studies, 264 participants; very low-certainty evidence). Gonadotropins with GnRH antagonist versus gonadotropins alone (14 studies) Three studies reported live birth rate per couple, and we are uncertain whether gonadotropins with GnRH antagonist improve live birth rate compared to gonadotropins (OR 1.5, 95% CI 0.52 to 4.39; I2 = 81%; 3 studies, 419 participants; very low-certainty evidence). This suggests that if the chance of a live birth following gonadotropins alone is 25.7%, the chance following gonadotropins combined with GnRH antagonist would be between 15.2% and 60.3%. We are also uncertain whether gonadotropins combined with GnRH antagonist lead to a higher multiple pregnancy rate compared with gonadotropins alone (OR 1.30, 95% CI 0.74 to 2.28; I2 = 0%; 10 studies, 2095 participants; moderate-certainty evidence). Gonadotropins with anti-oestrogens versus gonadotropins alone (2 studies) Neither of the studies reported data for live birth rate. We are uncertain whether gonadotropins combined with anti-oestrogens lead to a higher multiple pregnancy rate compared with gonadotropins alone, based on one study (OR 3.03, 95% CI 0.12 to 75.1; 1 study, 230 participants; low-certainty evidence). Aromatase inhibitors versus gonadotropins (6 studies) Two studies revealed that aromatase inhibitors may decrease live birth rate compared with gonadotropins (OR 0.49, 95% CI 0.34 to 0.71; I2=0%; 2 studies, 651 participants; low-certainty evidence). This suggests that if the chance of a live birth following gonadotropins alone is 31.9%, the chance of live birth following aromatase inhibitors would be between 13.7% and 25%. We are uncertain whether aromatase inhibitors compared with gonadotropins lead to a higher multiple pregnancy rate (OR 0.69, 95% CI 0.06 to 8.17; I2=77%; 3 studies, 731 participants; very low-certainty evidence). Aromatase inhibitors with gonadotropins versus anti-oestrogens with gonadotropins (8 studies) We are uncertain whether aromatase inhibitors combined with gonadotropins improve live birth rate compared with anti-oestrogens plus gonadotropins (OR 0.99, 95% CI 0.3 8 to 2.54; I2 = 69%; 3 studies, 708 participants; very low-certainty evidence). This suggests that if the chance of a live birth following anti-oestrogens plus gonadotropins is 13.8%, the chance following aromatase inhibitors plus gonadotropins would be between 5.7% and 28.9%. We are uncertain of the effect of aromatase inhibitors combined with gonadotropins compared to anti-oestrogens combined with gonadotropins on multiple pregnancy rate (OR 1.31, 95% CI 0.39 to 4.37; I2 = 0%; 5 studies, 901 participants; low-certainty evidence). AUTHORS' CONCLUSIONS Based on the available results, gonadotropins probably improve cumulative live birth rate compared with anti-oestrogens (moderate-certainty evidence). Gonadotropins may also improve cumulative live birth rate when compared with aromatase inhibitors (low-certainty evidence). From the available data, there is no convincing evidence that aromatase inhibitors lead to higher live birth rates compared to anti-oestrogens. None of the agents compared lead to significantly higher multiple pregnancy rates. Based on low-certainty evidence, there does not seem to be a role for different combined therapies, nor for adding GnRH agonists or GnRH antagonists in IUI programs.
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Affiliation(s)
- Astrid Ep Cantineau
- Department of Obstetrics and Gynaecology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | | | - Ben J Cohlen
- Department of Obstetrics and Gynaecology, Isala Clinics, Zwolle, Netherlands
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Ozelci R, Dilbaz S, Dilbaz B, Cırık DA, Yılmaz S, Tekin OM. Gonadotropin releasing hormone antagonist use in controlled ovarian stimulation and intrauterine insemination cycles in women with polycystic ovary syndrome. Taiwan J Obstet Gynecol 2019; 58:234-238. [PMID: 30910145 DOI: 10.1016/j.tjog.2019.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2018] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To evaluate the effect of the GnRH antagonist on gonadotropin ovulation induction in women with PCOS. MATERIALS AND METHODS A total of 175 intrauterine insemination (IUI) cycles in women with polycystic ovary syndrome (PCOS) were included in the study. Women in the control group (n = 87) underwent controlled ovarian stimulation (COS) with recombinant follicle stimulating hormone (r-FSH) only, while women in the study group (n = 88) were administered r-FSH plus cetrorelix. RESULTS As expected, the mean value of luteinizing hormone and progesterone, on the day of human chorionic gonadotropin administration were statistically significantly lower in patients receiving GnRH antagonist than the control group (p = 0.002). Premature luteinization occurred in only one of the patients in the GnRH antagonist group (1.1%) and in 15 of the 88 cycles in the control group (17.2%), showing a significant difference between the two groups (P = 0.001). The clinical pregnancy rate per cycle was higher in GnRH-antagonist group compared to the control group but the difference did not reach to a statistical significance (25% vs 14.9%, P = 0.096). CONCLUSIONS Adding GnRH-antagonist in COS/IUI cycles in women with PCOS resulted in a lower incidence of premature luteinization but did not improve pregnancy rates. However, owing to some benefits, antagonist therapy could be considered as a reasonable alternative to IVF in order to reduce PCOS patients'emotional distress.
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Affiliation(s)
- Runa Ozelci
- Department of Reproductive Endocrinology and Infertility, Etlik Zubeyde Hanım Women's Health Training and Research Hospital, Ankara, Turkey.
| | - Serdar Dilbaz
- Department of Reproductive Endocrinology and Infertility, Etlik Zubeyde Hanım Women's Health Training and Research Hospital, Ankara, Turkey
| | - Berna Dilbaz
- Department of Reproductive Endocrinology and Infertility, Etlik Zubeyde Hanım Women's Health Training and Research Hospital, Ankara, Turkey
| | - Derya Akdag Cırık
- Department of Reproductive Endocrinology and Infertility, Etlik Zubeyde Hanım Women's Health Training and Research Hospital, Ankara, Turkey
| | - Saynur Yılmaz
- Department of Reproductive Endocrinology and Infertility, Etlik Zubeyde Hanım Women's Health Training and Research Hospital, Ankara, Turkey
| | - Ozlem Moraloglu Tekin
- Department of Reproductive Endocrinology and Infertility, Etlik Zubeyde Hanım Women's Health Training and Research Hospital, Ankara, Turkey
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Vitagliano A, Saccone G, Noventa M, Borini A, Coccia ME, Nardelli GB, Saccardi C, Bifulco G, Litta PS, Andrisani A. Pituitary block with gonadotrophin-releasing hormone antagonist during intrauterine insemination cycles: a systematic review and meta-analysis of randomised controlled trials. BJOG 2019; 126:167-175. [PMID: 29862633 DOI: 10.1111/1471-0528.15269] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Several randomised controlled trials (RCTs) have investigated the usefulness of pituitary block with gonadotrophin-releasing hormone (GnRH) antagonists during intrauterine insemination (IUI) cycles, with conflicting results. OBJECTIVE The aim of the present systematic review and meta-analysis of RCTs was to evaluate the effectiveness of GnRH antagonist administration as an intervention to improve the success of IUI cycles. SEARCH STRATEGY Electronic databases (MEDLINE, Scopus, EMBASE, Sciencedirect) and clinical registers were searched from their inception until October 2017. SELECTION CRITERIA Randomised controlled trials of infertile women undergoing one or more IUI stimulated cycles with GnRH antagonists compared with a control group. DATA COLLECTION AND ANALYSIS The primary outcomes were ongoing pregnancy/live birth rate (OPR/LBR) and clinical pregnancy rate (CPR). Pooled results were expressed as odds ratio (OR) or mean differences with 95% confidence interval (95% CI). Sources of heterogeneity were investigated through sensitivity and subgroups analysis. The body of evidence was rated using GRADE methodology. Publication bias was assessed with funnel plot, Begg's and Egger's tests. MAIN RESULTS Fifteen RCTs were included (3253 IUI cycles, 2345 participants). No differences in OPR/LBR (OR 1.14, 95% CI 0.82-1.57, P = 0.44) and CPR (OR 1.28, 95% CI 0.97-1.69, P = 0.08) were found. Sensitivity and subgroup analyses did not provide statistical changes in pooled results. The body of evidence was rated as low (GRADE 2/4). No publication bias was detected. CONCLUSION Pituitary block with GnRH antagonists does not improve OPR/LBR and CPR in women undergoing IUI cycles. TWEETABLE ABSTRACT Pituitary block with GnRH antagonists does not improve the success of IUI cycles.
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Affiliation(s)
- A Vitagliano
- Department of Women and Children's Health, Unit of Gynaecology and Obstetrics, University of Padua, Padua, Italy
| | - G Saccone
- Department of Neuroscience Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - M Noventa
- Department of Women and Children's Health, Unit of Gynaecology and Obstetrics, University of Padua, Padua, Italy
| | - A Borini
- 9.Baby, Family and Fertility Centre Bologna, Bologna, Italy
| | - M E Coccia
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynaecology, Careggi University Hospital, University of Florence, Florence, Italy
| | - G B Nardelli
- Department of Women and Children's Health, Unit of Gynaecology and Obstetrics, University of Padua, Padua, Italy
| | - C Saccardi
- Department of Women and Children's Health, Unit of Gynaecology and Obstetrics, University of Padua, Padua, Italy
| | - G Bifulco
- Department of Neuroscience Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - P S Litta
- Department of Women and Children's Health, Unit of Gynaecology and Obstetrics, University of Padua, Padua, Italy
| | - A Andrisani
- Department of Women and Children's Health, Unit of Gynaecology and Obstetrics, University of Padua, Padua, Italy
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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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Gonadotropin Alone is a Better Drug for Ovarian Stimulation than in Combination with Clomiphene in Intrauterine Insemination. J Obstet Gynaecol India 2016; 66:333-8. [DOI: 10.1007/s13224-015-0686-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 02/19/2015] [Indexed: 11/26/2022] Open
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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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Jain S, Majumdar A. Impact of gonadotropin-releasing hormone antagonist addition on pregnancy rates in gonadotropin-stimulated intrauterine insemination cycles. J Hum Reprod Sci 2016; 9:151-158. [PMID: 27803582 PMCID: PMC5070396 DOI: 10.4103/0974-1208.192053] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES: The objective of the study is to evaluate the efficacy of gonadotropin-releasing hormone (GnRH) antagonist in improving clinical pregnancy rate in gonadotropin-stimulated intrauterine insemination (IUI) cycles in patients of unexplained infertility. STUDY DESIGN: This was a prospective, randomized case-controlled study. SETTINGS: The study was conducted in the infertility clinic of a tertiary care center. MATERIALS AND METHODS: Four hundred twenty-seven women undergoing IUI following controlled ovarian stimulation with gonadotropins (recombinant follicle-stimulating hormone [r-FSH] 75 IU/day) were randomly divided into two groups. Women in Group I received GnRH antagonist (Cetrorelix 0.25 mg/day) in a multiple dose flexible protocol. Women in Group II received r-FSH alone. Ovulatory trigger was given with human chorionic gonadotropin 5000 IU when dominant follicle was ≥18 mm. IUI was performed within 44–48 h. Both groups received similar luteal phase support. Primary outcome measure was clinical pregnancy rate. The trial was powered to detect an absolute increase in clinical pregnancy rate by 13% from an assumed 20% clinical pregnancy rate in the control group, with an alpha error level of 0.05 and a beta error level of 0.20. RESULTS: Clinical pregnancy rate in Groups I and II was 27.6% (n = 56) and 26.5% (n = 54), respectively (P=0.800). Ongoing pregnancy and multiple pregnancy rates were likewise similar between the groups. CONCLUSIONS: Addition of GnRH antagonist to gonadotropin-stimulated IUI cycles results in no significant difference in clinical pregnancy rate.
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Affiliation(s)
- Shikha Jain
- Centre of IVF and Human Reproduction, Sir Ganga Ram Hospital, New Delhi, India
| | - Abha Majumdar
- Centre of IVF and Human Reproduction, Sir Ganga Ram Hospital, New Delhi, India
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Dansuk R, Gonenc AI, Sudolmus S, Yucel O, Sevket O, Köroğlu N. Effect of GnRH antagonists on clinical pregnancy rates in ovulation induction protocols with gonadotropins and intrauterine insemination. Singapore Med J 2015; 56:353-6. [PMID: 25532515 PMCID: PMC4469855 DOI: 10.11622/smedj.2014192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Intrauterine insemination (IUI) after controlled ovarian hyperstimulation (COH) was applied to selected infertile patients to determine the effect of gonadotropin-releasing hormone (GnRH) antagonists in IUI cycles, in which recombinant follicle-stimulating hormone (rFSH) had been used for COH. METHODS This study was conducted between April 1, 2009 and June 10, 2009, and involved a total of 108 patients. These patients had primary or secondary infertility, which resulted in an indication for IUI, and they each received two cycles of ovarian stimulation treatment with clomiphene citrate. The patients were randomised into two groups--patients in group A received rFSH + GnRH antagonist (n = 45), while those in group B received only rFSH (n = 63). RESULTS The mean age of the patients was 31.84 ± 3.73 years and the mean body mass index (BMI) was 24.40 ± 1.88 kg/m(2). The mean age and BMI of the patients in groups A and B were not significantly different. There was no significant difference in the mean total rFSH dose administered (988.33 IU in group A and 871.83 IU in group B). When compared to group B, the mean number of follicles that were > 16 mm on the human chorionic gonadotropin (HCG) trigger day was significantly higher in group A (1.58 and 1.86, respectively; p < 0.05). When the two groups were compared, there were no statistically significant differences in the number of cancelled cycles due to premature luteinisation (none in group A vs. two in group B) and the rate of clinical pregnancy (8.9% in group A vs. 7.9% in group B). CONCLUSION No significant improvement in the clinical pregnancy rates was observed when GnRH antagonists were used in COH + IUI cycles, despite the significant increase in the number of follicles that were > 16 mm on HCG trigger day.
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Affiliation(s)
- Ramazan Dansuk
- Department of Obstetrics and Gynecology, Bezmialem Vakif University, School of Medicine, Istanbul, Turkey
| | | | - Sinem Sudolmus
- Department of Obstetrics and Gynecology, Bezmialem Vakif University, School of Medicine, Istanbul, Turkey
| | - Oguz Yucel
- Suleymaniye Women Health Training Hospital, Istanbul, Turkey
| | - Osman Sevket
- Department of Obstetrics and Gynecology, Bezmialem Vakif University, School of Medicine, Istanbul, Turkey
| | - Nadiye Köroğlu
- Department of Obstetrics and Gynecology, Bezmialem Vakif University, School of Medicine, Istanbul, Turkey
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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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Luo S, Li S, Li X, Bai Y, Jin S. Effect of gonadotropin-releasing hormone antagonists on intrauterine insemination cycles in women with polycystic ovary syndrome: a meta-analysis. Gynecol Endocrinol 2014; 30:255-9. [PMID: 24299151 DOI: 10.3109/09513590.2013.863862] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Polycystic ovary syndrome (PCOS) patients undergoing controlled ovarian stimulation and intrauterine insemination (COS/IUI) often face the risk of premature luteinization, which may result in lower pregnancy rate and higher miscarriage rate. This review was performed to identify if adjuvant treatment with GnRH antagonist (GnRH-ant) could effectively improve the clinical outcome of patients with PCOS undergoing COS/IUI. A literature search was conducted on the PubMed, EMBASE and Cochrane library databases. Two randomized controlled trials were included in this review, enrolling a total of 333 cycles. The patients who received GnRH-ant treatment had lower progesterone levels on the hCG day and a reduced premature luteinization rate. However, the rates of live birth, clinical pregnancy and miscarriage did not significantly differ between the GnRH-ant supplementation group and control group. In conclusion, although the existing randomized controlled trials indicate that GnRH-ant can effectively decrease the premature luteinizaton rate, evidence to support its use to improve clinical pregnancy outcomes in PCOS patients undergoing COS/IUI treatment is insufficient.
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Affiliation(s)
- Shan Luo
- Division of Reproductive Medical Center, West China Second University Hospital of Sichuan University , Sichuan , China
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12
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Baird D, Bhattacharya S, Devroey P, Diedrich K, Evers J, Fauser B, Jouannet P, Pellicer A, Walters E, Crosignani P, Fraser L, Geraedts J, Gianaroli L, Glasier A, Liebaers I, Sunde A, Tapanainen J, Tarlatzis B, Van Steirteghem A, Veiga A. Failures (with some successes) of assisted reproduction and gamete donation programs. Hum Reprod Update 2013; 19:354-65. [DOI: 10.1093/humupd/dmt007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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13
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Ragni G, Levi-Setti PE, Fadini R, Brigante C, Scarduelli C, Alagna F, Arfuso V, Mignini-Renzini M, Candiani M, Paffoni A, Somigliana E. Clomiphene citrate versus high doses of gonadotropins for in vitro fertilisation in women with compromised ovarian reserve: a randomised controlled non-inferiority trial. Reprod Biol Endocrinol 2012; 10:114. [PMID: 23249758 PMCID: PMC3551801 DOI: 10.1186/1477-7827-10-114] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Accepted: 12/14/2012] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The aim of the present randomised controlled non-inferiority trial is to test whether in women with compromised ovarian reserve requiring in vitro fertilisation, a protocol of ovarian stimulation using exclusively clomiphene citrate performs similarly to a regimen with high doses of gonadotropins. METHODS Women with day 3 serum FSH > 12 IU/ml on at least two occasions or previous poor response to hyper-stimulation were recruited at four Italian infertility units. Selected women were allocated to clomiphene citrate 150 mg/day from day 3 to day 7 of the cycle (n=145) or to a short protocol with GnRH agonist 0.1 mg and recombinant FSH 450 IU daily (n=146). They were randomised by means of a computer-generated list into two groups. The study was not blinded. The main outcome of the study was the delivery rate per started cycle. RESULTS The study was interrupted after the scheduled two years of recruitment before reaching the sample size. 148 women were allocated to clomiphene citrate and 156 to the short protocol with high doses of gonadotropins; 124 and 125 participants were analysed in the groups, respectively. Women allocated to high doses of gonadotropins retrieved more oocytes and had a higher probability to perform embryo-transfer. However, the chances of success were similar. The delivery rate per started cycle in women receiving clomiphene citrate and high-dose gonadotropins was 3% (n=5) and 5% (n=7), respectively (p=0.77). The mean estimated cost per delivery in the two groups was 81,294 and 113,107 Euros, respectively. No side-effects or adverse events were observed. CONCLUSIONS In women with compromised ovarian reserve selected for in vitro fertilisation, ovarian stimulation with clomiphene citrate or high-dose gonadotropins led to similar chances of pregnancy but the former is less expensive. TRIAL REGISTRATION Trial registered on http://www.clinicaltrials.gov (NCT01389713).
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Affiliation(s)
- Guido Ragni
- Infertility Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo E Levi-Setti
- Department of Gynecology and Reproductive Medicine, IRCCS Istituto Clinico Humanitas, Rozzano, Italy
| | - Rubens Fadini
- Reproductive Medicine Unit BIOGENESI, Istituti Clinici Zucchi, Monza, Italy
| | - Claudio Brigante
- Obstetrics and Gynecology Unit, Università Vita-Salute, Fondazione Ospedale San Raffaele, Milan, Italy
| | - Claudia Scarduelli
- Infertility Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Federica Alagna
- Infertility Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Veronica Arfuso
- Department of Gynecology and Reproductive Medicine, IRCCS Istituto Clinico Humanitas, Rozzano, Italy
| | | | - Massimo Candiani
- Obstetrics and Gynecology Unit, Università Vita-Salute, Fondazione Ospedale San Raffaele, Milan, Italy
| | - Alessio Paffoni
- Infertility Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Edgardo Somigliana
- Infertility Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
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Kamath MS, R R, Bhave P, K M, T K A, George K. Effectiveness of GnRH antagonist in intrauterine insemination cycles. Eur J Obstet Gynecol Reprod Biol 2012; 166:168-72. [PMID: 23083636 DOI: 10.1016/j.ejogrb.2012.09.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2012] [Revised: 07/19/2012] [Accepted: 09/21/2012] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of GnRH antagonists in women undergoing controlled ovarian stimulation and intrauterine insemination cycles (COS/IUI). STUDY DESIGN Randomized controlled trial. Recruited women were randomized into two groups: GnRH antagonist and control group. The primary outcomes were incidence of premature LH surge and clinical pregnancy rates. RESULTS One hundred and forty-one consecutive women were included in the study, with 70 in the antagonist group and 71 in the control arm. The baseline clinical characteristics were similar in both groups. The incidence of premature LH surge and premature luteinization was lower in the antagonist group as compared to the control group (5% vs. 10.3%, P=0.45 and 5% vs. 13.8, P=0.31) but not statistically significant. The clinical pregnancy rates were lower in the antagonist group (2.8% vs. 10%, P=0.12), which was also not statistically significant. CONCLUSION The addition of GnRH antagonist during controlled ovarian stimulation and intrauterine insemination cycles does not lead to improvement in clinical pregnancy rates.
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Affiliation(s)
- Mohan S Kamath
- Reproductive Medicine Unit, Christian Medical College Hospital, Vellore 632004, Tamil Nadu, India
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Peut-on éviter le travail du week-end en Assistance médicale à la procréation ? ACTA ACUST UNITED AC 2012; 40:472-5. [DOI: 10.1016/j.gyobfe.2012.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2012] [Accepted: 06/24/2012] [Indexed: 11/20/2022]
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Streda R, Mardesic T, Sobotka V, Koryntova D, Hybnerova L, Jindra M. Comparison of different starting gonadotropin doses (50, 75 and 100 IU daily) for ovulation induction combined with intrauterine insemination. Arch Gynecol Obstet 2012; 286:1055-9. [PMID: 22736041 PMCID: PMC3439605 DOI: 10.1007/s00404-012-2414-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 06/04/2012] [Indexed: 11/24/2022]
Abstract
Purpose To prevent multiple pregnancies the goal of ovulation induction by gonadotropins is to achieve only mono-follicular development. The most important issue is therefore to determine the starting dose. The aim of this study is to compare three different starting doses of follitropin beta to assess the lowest effective dose. Methods We evaluated 92 cycles with ovarian stimulation for patients with unexplained infertility, anovulatory disorder or mild male factor. We prospectively divided patients into 50, 75 and 100 IU groups based on patients’ response to clomiphene citrate treatment. Results We performed 87 intrauterine inseminations (95 % of cycles with ovulation induction). Five cycles were cancelled. We achieved 15 pregnancies; total pregnancy rate was 18 %. Pregnancy rate was 22, 10 and 28 % in 50, 75 and 100 IU follitropin beta groups. The average number of follicles was 2.0 ± 0.8, 2.2 ± 1.1 and 2.5 ± 1.8 (ns), total dose of gonadotropins (IU) 483 ± 192, 600 ± 151 and 830 ± 268 (p < 0.001), respectively. We observed one case of twins in 75 and 100 IU treatment group, as well (25 % risk). Conclusions This study suggests that based on the dose which was chosen according to clomiphene citrate response, all treatment regimes were effective for ovulation induction. 50 IU of follitropin beta daily is the appropriate starting dose to support ovulation for clomiphene citrate-sensitive women. The disadvantage may be an increased risk of cycle cancellation due to low ovarian response. Daily doses 75 or 100 IU of rFSH increase total consumption of gonadotropins.
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Affiliation(s)
- Robert Streda
- Sanatorium Pronatal, Na Dlouhé Mezi 4/12, Prague, Czech Republic.
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17
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Baird DT, Balen A, Escobar-Morreale HF, Evers JLH, Fauser BCJM, Franks S, Glasier A, Homburg R, La Vecchia C, Devroey P, Diedrich K, Fraser L, Gianaroli L, Liebaers I, Sunde A, Tapanainen JS, Tarlatzis B, Van Steirteghem A, Veiga A, Crosignani PG, Evers JLH. Health and fertility in World Health Organization group 2 anovulatory women. Hum Reprod Update 2012; 18:586-99. [DOI: 10.1093/humupd/dms019] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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18
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Matorras R, Soler AVI, Ramon O, Burgos J, Abanto E, González M, Múgica J, Corcóstegui B, Pijoan JI, Exposito A. Prognostic value of serum progesterone and LH values on the day of hCG administration in IUI GnRH antagonist cycles. Gynecol Endocrinol 2012; 28:157-61. [PMID: 21801119 DOI: 10.3109/09513590.2011.588747] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [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 LH surge and progesterone rise in IUI cycles under gonadotropin stimulation with GnRH antagonist coadministration on pregnancy rates (PR). STUDY DESIGN The population under study consisted of 152 women prospectively studied and subjected to IUI. RESULTS The higher the progesterone cutoff value, the lower the PR were 26.5% and 10.9% when the cutoff was 1 ng/mL, 26.0% and 8.6% when the cutoff was 1.2 ng/mL, 25.6% and 7.1% when the cutoff was 1.4 ng/mL and 25.3% and 0% when the cutoff was 1.6 ng/mL. CONCLUSION In IUI cycles under GnRH antagonist coadministration, serum progesterone levels over 1.0 ng/mL are associated with lower PR, the higher the progesterone levels, the lower the PR.
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Sarhan A, Beydoun H, Jones HW, Bocca S, Oehninger S, Stadtmauer L. Gonadotrophin ovulation induction and enhancement outcomes: analysis of more than 1400 cycles. Reprod Biomed Online 2011; 23:220-6. [PMID: 21665547 DOI: 10.1016/j.rbmo.2011.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Revised: 05/09/2011] [Accepted: 05/09/2011] [Indexed: 10/18/2022]
Abstract
Ovulation induction (OI) or ovulation enhancement (OE) with gonadotrophins can be a reasonable treatment option for patients with a variety of infertility diagnoses. It must be used with extensive monitoring and management given the risk of multiple pregnancy,especially high-order multiples. This retrospective study evaluated per cycle outcomes of a large cohort of 1452 gonadotrophin OI/OE cycles at an academic infertility centre, and the efficacy of specific guidelines in limiting multiple pregnancy. The lowest possible gonadotrophin doses were used and cycle cancellation was recommended if more than three dominant follicles were present, and/or ifserum oestradiol was above 1500 pg/ml. Overall, pregnancy rate (PR) was 12% and live birth rate was 7.7%, with an increasing trend in younger patients (P = 0.0002 and <0.0001, respectively). Multiple clinical PR was 2.6% with 1.9% twins and 0.7% triplets and above.The birthweight of a singleton from a vanishing twin pregnancy (n = 8)was significantly lower than other singletons (2882 g versus 3250 g,P = 0.013). Reducing multiple pregnancies from OI/OE cycles remains an important and challenging goal. In this large cohort, high-order multiple clinical PR was limited to 0.7% per cycle by using specific management strategies while maintaining a reasonable PR.
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Affiliation(s)
- Abbaa Sarhan
- The Jones Institute for Reproductive Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, 601 Colley Avenue, Norfolk, VA 23507, USA.
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Al-Inany HG, Youssef MA, Aboulghar M, Broekmans F, Sterrenburg M, Smit J, Abou-Setta AM. Gonadotrophin-releasing hormone antagonists for assisted reproductive technology. Cochrane Database Syst Rev 2011:CD001750. [PMID: 21563131 DOI: 10.1002/14651858.cd001750.pub3] [Citation(s) in RCA: 162] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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-estrogenic side-effects, flare-up, or long down-regulation period associated with agonists. The antagonists directly and rapidly inhibit gonadotropin 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 regimes 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. OBJECTIVES To evaluate the effectiveness and safety of gonadotrophin-releasing hormone (GnRH) antagonists with the standard long protocol of GnRH agonists for controlled ovarian hyperstimulation in assisted conception cycle SEARCH STRATEGY We performed electronic searches of major databases, for example Cochrane Menstrual Disorders and Subfertility Group Specialised Register, CENTRAL, MEDLINE, EMBASE (from 1987 to April 2010); 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). A date limited search of Cochrane Menstrual Disorders and Subfertility Group Specialised Register, CENTRAL from April 2010 to April 2011 was run. Eighteen studies have been entered into the Classification pending references section of this update. These studies will be appraised for inclusion or exclusion in the next update of this review, due April 2012. SELECTION CRITERIA Two review authors independently screened the relevant citations for randomised controlled trials (RCTs) comparing different agonist versus antagonist protocols in women undergoing IVF or ICSI. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial risk of bias and extracted data. If relevant data were missing or unclear, the authors were contacted for clarification. MAIN RESULTS Forty-five RCTs (n = 7511) comparing the antagonist to the long agonist protocols fulfilled the inclusion criteria. There was no evidence of a statistically significant difference in rates of live-births (9 RCTs; odds ratio (OR) 0.86, 95% CI 0.69 to 1.08) or ongoing pregnancy (28 RCTs; OR 0.87, 95% CI 0.77 to 1.00). There was a statistically significant lower incidence of OHSS in the GnRH antagonist group (29 RCTs; OR 0.43, 95% CI 0.33 to 0.57). AUTHORS' CONCLUSIONS The use of antagonist compared with long GnRH agonist protocols was associated with a large reduction in OHSS and there was no evidence of a difference in live-birth rates.
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Affiliation(s)
- Hesham G Al-Inany
- Obstetrics & Gynaecology, Faculty of Medicine, Cairo University, 8 Moustapha Hassanin St, Manial, Cairo, Egypt
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Cantineau AEP, Cohlen BJ, Klip H, Heineman MJ, Hoek A, Lambalk CB, Hamilton CJ, Van Bommel PF, van Dop PA, van der Heijden PFM, de Sutter P, D'Hooghe T, Manger PA, Ombelet W, Santema JG. The addition of GnRH antagonists in intrauterine insemination cycles with mild ovarian hyperstimulation does not increase live birth rates--a randomized, double-blinded, placebo-controlled trial. Hum Reprod 2011; 26:1104-11. [DOI: 10.1093/humrep/der033] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Bakas P, Konidaris S, Liapis A, Gregoriou O, Tzanakaki D, Creatsas G. Role of gonadotropin-releasing hormone antagonist in the management of subfertile couples with intrauterine insemination and controlled ovarian stimulation. Fertil Steril 2011; 95:2024-8. [PMID: 21334613 DOI: 10.1016/j.fertnstert.2011.01.167] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Revised: 01/25/2011] [Accepted: 01/26/2011] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess whether the clinical pregnancy rate of patients treated with recombinant FSH and IUI can be improved by the addition of a GnRH antagonist. DESIGN Prospective, controlled study. SETTING Reproductive medicine clinic. PATIENT(S) Ninety-three patients with primary or secondary infertility. INTERVENTION(S) Patients were allocated to controlled ovarian stimulation with recombinant FSH (50-150 IU/d) only (control group, n=45) or to recombinant FSH (50-150 IU/d) plus ganirelix (0.25 mg/d, starting when the leading follicle was ≥16 mm; n=48). A single insemination was performed 36 hours after hCG was given (10,000 IU, IM) in both groups. Both groups were allowed at least three cycles. MAIN OUTCOME MEASURE(S) Clinical pregnancy rate, premature luteinization rate, and follicular development. RESULT(S) Clinical pregnancy rate (22% vs. 11%), cumulative pregnancy rate (52% vs. 31%), and number of mature follicles (2.1±1.08 vs. 1.4±0.95) were statistically significantly higher in the ganirelix group compared with the control group. The premature luteinization rate was significantly lower in the ganirelix group (1.7% vs. 17.5%). CONCLUSION(S) The use of a GnRH antagonist in conjunction with controlled ovarian stimulation and IUI significantly increases pregnancy rates and reduces the incidence of premature luteinization.
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Affiliation(s)
- Panagiotis Bakas
- Second Department of Obstetrics and Gynecology, Aretaieio Hospital, University of Athens, Athens, Greece.
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23
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Steward RG, Gill I, Williams DB, Witz CA, Griffith J, Haddad GF. Cetrorelix lowers premature luteinization rate in gonadotropin ovulation induction-intrauterine insemination cycles: a randomized-controlled clinical trial. Fertil Steril 2010; 95:434-6. [PMID: 20810107 DOI: 10.1016/j.fertnstert.2010.07.1076] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Revised: 07/16/2010] [Accepted: 07/22/2010] [Indexed: 11/29/2022]
Abstract
Attempting to compare the rates of premature luteinization (PL), clinical pregnancy, and cycle cancellation in ovulation induction-intrauterine insemination (OI-IUI) cycles with and without the GnRH antagonist, cetrorelix, a randomized-controlled trial was undertaken in which patients were randomized to one of two OI-IUI protocols. Those in the cetrorelix arm showed a significantly reduced rate of PL and no change in clinical pregnancy or cycle cancellation rate, leading to the conclusion that GnRH antagonists can decrease the rate of PL, but appear to have no effect on pregnancy or cycle cancellation in gonadotropin OI-IUI cycles.
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Affiliation(s)
- Ryan G Steward
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Texas Health Science Center at Houston, Houston, Texas 77225-0708, USA.
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Kocak M, Dilbaz B, Demir B, Taşci Y, Tarcan A, Dede S, Haberal A. Lyophilised hMG versus rFSH in women with unexplained infertility undergoing a controlled ovarian stimulation with intrauterine insemination: a prospective, randomised study. Gynecol Endocrinol 2010; 26:429-34. [PMID: 20175705 DOI: 10.3109/09513591003632175] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To compare the efficacy of lyophilised urinary hMG (HP-hMG) with recombinant FSH (rFSH) in women with unexplained infertility undergoing a controlled ovarian hyperstimulation with intrauterine insemination (IUI). METHODS Forty-nine consecutively seen women with unexplained infertility were randomised to a controlled ovarian hyperstimulation with IUI cycle either with rFSH or HP-hMG. The outcome was compared by independent samples t-test. RESULTS The mean patient age and duration of infertility were not different (29.5 +/- 5.7 and 4.9 +/- 2.7 years in rFSH; 28.8 +/- 3.2 and 6 +/- 4.2 in HP-hMG group) (p = 0.6 and p = 0.2). The mean body mass index (BMI) and basal hormones were similar. Total dose of gonadotropin used (710 +/- 236 vs. 636 +/- 185 IU) and duration of the cycles (9 +/- 2.1 vs. 8.3 +/- 2.3 days) showed no significant difference (p = 0.2). Number of follicles, serum oestradiol (E2), and the endometrial thickness on the day of hCG were comparable. Two singletons in each group were obtained. CONCLUSIONS These data suggest that HP-hMG and rFSH may be equally suitable in mild ovarian stimulation for unexplained infertility. Further data derived from larger study population are needed to determine whether higher amounts of two gonadotropins in this subgroup might produce any benefits or unfavourable effects.
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Affiliation(s)
- Muberra Kocak
- Etlik Zübeyde Hanim Womens' Health Teaching and Research Hospital, Department of Obstetrics and Gynecology, Infertility Unit, Ankara, Turkey.
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Ertunc D, Tok EC, Savas A, Ozturk I, Dilek S. Gonadotropin-releasing hormone antagonist use in controlled ovarian stimulation and intrauterine insemination cycles in women with polycystic ovary syndrome. Fertil Steril 2010; 93:1179-84. [PMID: 19200979 DOI: 10.1016/j.fertnstert.2008.11.030] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2008] [Revised: 10/15/2008] [Accepted: 11/26/2008] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To observe the effects of ganirelix on controlled ovarian stimulation and intrauterine insemination (COS/IUI) cycles in women with polycystic ovary syndrome (PCOS). DESIGN Prospective, randomized, controlled clinical study. SETTING An academic clinical research center. PATIENT(S) Women with PCOS and anovulatory infertility undergoing COS/IUI. INTERVENTION(S) Recombinant FSH therapy was started on day 3. In women assigned to the control group (n = 47), treatment was continued up to the day of hCG administration. In patients assigned to receive GnRH antagonist (n = 42), ganirelix was added when the leading follicle was > or =14 mm. MAIN OUTCOME MEASURE(S) Pregnancy rates, serum E(2), P, and LH levels, and follicle numbers at hCG day, prevalence of premature luteinization, and cost of stimulation. RESULT(S) Serum E(2), P, and LH levels were significantly lower in the ganirelix group. Although premature luteinization and cycle cancellation was encountered less in the ganirelix group, the pregnancy rates per cycle were similar (15.4% vs. 10.7%). Patients would pay 6,153 dollars more for each pregnancy when using ganirelix. CONCLUSION(S) Gonadotropin-releasing hormone antagonist resulted in more monofollicular development, less premature luteinization, and less cycle cancellation in IUI cycles of patients with PCOS; however, the cost of stimulation increased without an improvement in pregnancy rates.
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Affiliation(s)
- Devrim Ertunc
- Department of Obstetrics and Gynecology, School of Medicine, Mersin University, Mersin, Turkey.
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Crosignani P. Prevention of multiple pregnancy. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2010. [DOI: 10.1016/j.mefs.2010.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Beyer D. Intrauterine Insemination (IUI). GYNAKOLOGISCHE ENDOKRINOLOGIE 2009. [DOI: 10.1007/s10304-009-0320-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Martinez-Salazar J, Cerrillo M, Quea G, Pacheco A, Garcia-Velasco JA. GnRH antagonist ganirelix prevents premature luteinization in IUI cycles: rationale for its use. Reprod Biomed Online 2009; 19:156-61. [PMID: 19712548 DOI: 10.1016/s1472-6483(10)60066-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study evaluated the efficacy of a gonadotrophin-releasing hormone antagonist (GnRHa) to prevent premature luteinization (PL) and examined its impact on intrauterine insemination (IUI) cycle outcome. A total of 662 patients who were undergoing IUI were evaluated. Ovarian stimulation was started on day 3 with recombinant (r)FSH, followed by the GnRHa and recombinant human chorionic gonadotrophin (rHCG). The overall incidence of PL was 11.5%. In patients with and without PL, the pregnancy rates (PR) were 22.4 (17/76) and 17.7% (104/586) respectively. Patients with PL were divided into two groups: (i) those with increased serum progesterone [PR was 10.7% (3/28) in this group]; and (ii) patients with elevated serum LH but normal progesterone concentrations [PR was 29.2% (14/48) in this group]. Patients in the first group who did not become pregnant (n = 22) were administered GnRHa in a second IUI cycle, and the PR was 18.1%; however, some patients (n = 6; 27.3%) in this group still had high serum progesterone concentrations. In the second group, patients (n = 26) with elevated serum LH in the previous cycle were administered GnRHa in another IUI and the PR was 23.1%. Use of a GnRHa in patients with PL who have had a previous unsuccessful IUI may be an alternative in future attempts.
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Abstracts of the First World Congress on Twin Pregnancy. Venice, Italy. April 16-18, 2009. J Matern Fetal Neonatal Med 2009; 22 Suppl 1:20-70. [PMID: 19294582 DOI: 10.1080/14767050902777811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Freiesleben NLC, Lossl K, Bogstad J, Bredkjaer HE, Toft B, Loft A, Bangsboll S, Pinborg A, Budtz-Jørgensen E, Andersen AN. Predictors of ovarian response in intrauterine insemination patients and development of a dosage nomogram. Reprod Biomed Online 2009; 17:632-41. [PMID: 18983747 DOI: 10.1016/s1472-6483(10)60310-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of this prospective study was to identify predictors of ovarian response in ovulatory patients treated with low-dose recombinant FSH (rFSH), gonadotrophin-releasing hormone antagonist and intrauterine insemination (IUI), and to develop an rFSH dosage nomogram based on the findings. Patients (n = 159) were stimulated with a starting dose of 75 IU rFSH/day. Ten parameters were investigated as possible predictors of the number of mature follicles >or=15 mm: age, spontaneous cycle length, body weight, body mass index, smoking status, total ovarian volume, total number of antral follicles, total Doppler score of the ovarian stromal blood flow, baseline FSH and oestradiol. Simple and multiple linear regressions were used for the statistical analysis. Appropriate ovarian response was defined as two to three mature follicles. Body weight (P = 0.001) and the number of antral follicles (P = 0.004) were the strongest independent predictive factors of the number of mature follicles. In conclusion, body weight and antral follicle count may be used to achieve appropriate ovarian response for IUI in ovulatory patients. Based on this, a simple rFSH dosage nomogram was developed for individual ovarian stimulation prior to IUI.
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Affiliation(s)
- N L C Freiesleben
- The Fertility Clinic, Department 4071, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark.
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Cohlen BJ. Should luteal phase support be introduced in ovarian stimulation/IUI programmes? An evidence-based review. Reprod Biomed Online 2009. [DOI: 10.1016/s1472-6483(10)61067-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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van Rumste M, Custers I, van der Veen F, van Wely M, Evers J, Mol B. The influence of the number of follicles on pregnancy rates in intrauterine insemination with ovarian stimulation: a meta-analysis. Hum Reprod Update 2008; 14:563-70. [DOI: 10.1093/humupd/dmn034] [Citation(s) in RCA: 132] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Meldrum DR, Cassidenti DL, Rosen GF, Yee B, Wisot AL. Oral contraceptive pretreatment and half dose of ganirelix does not excessively suppress LH and may be an excellent choice for scheduling IUI cycles. J Assist Reprod Genet 2008; 25:417-20. [PMID: 18758937 DOI: 10.1007/s10815-008-9244-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2008] [Accepted: 08/07/2008] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To assess the effects of using a reduced dose of ganirelix with oral contraceptive pretreatment in a pilot study of COH using pure FSH for intrauterine insemination (IUI) METHODS: Patients received oral contraceptive (OC; 30 microg ethinyl estradiol/150 microg desogestrel) for 14-21 days and rFSH (50-225 IU/day SC) was started on day 4 after OC discontinuation. Ganirelix acetate (125 microg/day) was started with a lead follicle diameter of 14 mm. RESULTS Of the 25 subjects who started oral contraceptives, one was cancelled due to an excessive response, and one subject was not included in the analysis because she did not receive ganirelix until the lead follicle was 18 mm. Median (range) starting FSH dose was 100 (50-225), cumulative rFSH dose was 1000 (675-2175) IU over 10 (9-17) days. Duration of ganirelix acetate treatment was 4.0 (2-5) days. Seven subjects (30.4%) delivered ten babies (three pregnancies were twins). There were no biochemical pregnancies or miscarriages. Of the 16 subjects with measurement of LH on the day of HCG administration, only one was under 0.5 mIU/ml (0.4), and only one was over 10 mIU/ml (17.7), and that subject delivered twins. CONCLUSION OC pretreatment afforded flexibility in scheduling while a reduced dose of ganirelix avoided excessive suppression of LH. The excellent results in this pilot study for IUI suggest this regimen could be further evaluated for scheduling IUI and IVF cycles.
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Affiliation(s)
- David R Meldrum
- Reproductive Partners Medical Group, Redondo Beach, CA 90277, USA.
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Pasquier M, Maitrot L, Leperlier F, Dehghani C, Snaifer E, Durnerin IC, Hugues JN. [The use of GnRH antagonists in ovarian stimulation for intrauterine inseminations: is there any interest?]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2008; 36:644-649. [PMID: 18539072 DOI: 10.1016/j.gyobfe.2008.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2007] [Accepted: 03/30/2008] [Indexed: 05/26/2023]
Abstract
The use of the GnRH antagonists during ovarian stimulation for intrauterine insemination is relatively recent. The primary aim was to improve the timing of the inseminations on working days. However, according to published data, the consequences on pregnancy rate remain uncertain. Moreover, the impact of this strategy on stimulation's parameters, specifically on the size of the follicle cohort, should be better assessed.
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Affiliation(s)
- M Pasquier
- Service de médecine de la reproduction, université Paris-XIII, CHU Jean-Verdier, avenue du 14-Juillet, 93140 Bondy, France.
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Kosmas IP, Tatsioni A, Kolibianakis EM, Verpoest W, Tournaye H, Van der Elst J, Devroey P. Effects and clinical significance of GnRH antagonist administration for IUI timing in FSH superovulated cycles: a meta-analysis. Fertil Steril 2007; 90:367-72. [PMID: 17936285 DOI: 10.1016/j.fertnstert.2007.06.064] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2007] [Revised: 06/21/2007] [Accepted: 06/21/2007] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To compare the administration of GnRH antagonist in gonadotropin intrauterine insemination (IUI) cycles with cycles where no intervention took place. DESIGN Meta-analysis of published prospective randomized trials. PATIENTS(S) Five hundred twenty-one patients who were administered a GnRH antagonist and 548 conservatively treated patients who served as control subjects were included in the meta-analysis. INTERVENTION(S) STUDY SELECTION Prospective trials were retrieved from Medline and Cochrane Library (last update October 2006). Random effect analysis was used in this meta-analysis. Two independent reviewers performed data extraction. MAIN OUTCOME MEASURE(S) Clinical pregnancy rates. RESULT(S) Six comparisons were retrieved including 1,069 patients. Higher pregnancy rates were found in the randomized controlled trials (odds ratio [OR] 1.56, 95% confidence interval [CI] 1.05-2.33) when a GnRH antagonist was added to a gonadotropin superovulated IUI protocol. Early published studies with smaller sample sizes showed stronger associations (OR 2.31, 95% CI 1.15-4.63) than later studies (OR 1.32, 95% CI 0.79-2.23). CONCLUSION(S) From the randomized controlled trials of this meta-analysis, it is clear that allowing for follicle growth and avoiding premature LH rise, increased pregnancy rates are observed with GnRH antagonist administration. A parallel trend for multiple pregnancy rates in the GnRH antagonist group was observed, although this did not reach statistical significance. The flexible regimen was widely used. This meta-analysis of early data might enhance further research in this direction.
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Affiliation(s)
- Ioannis P Kosmas
- Center for Reproductive Medicine, Dutch-Speaking Brussels Free University, Brussels, Belgium.
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