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Prieto B, Diaz-Nuñez M, Lainz L, Vendrell A, Rabanal A, Iglesias M, Jauregui T, Corcostegui B, Matorras A, Perez S, Matorras R. Aspiration of excess follicles before intrauterine insemination in high response cycles. Reprod Med Biol 2022; 21:e12470. [PMID: 35781922 PMCID: PMC9241166 DOI: 10.1002/rmb2.12470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 05/12/2022] [Accepted: 05/23/2022] [Indexed: 11/11/2022] Open
Abstract
Purpose To assess the outcome of excess follicle aspiration before intrauterine insemination (EFABI) in intrauterine insemination (IUI) cycles with 4-6 follicles ≥14 mm. Methods A retrospective case-control study with 1559 patients undergoing IUI (donor and husband's sperm), of whom 86 underwent EFABI. We studied also an historical series of 2213 patients before EFABI implementation. For 3.5 years, all women undergoing IUI developing 4-6 follicles ≥14 mm were offered EFABI on the day of hCG administration. Pregnancy rates (PRs), multiple PRs, and adverse effects were measured. Results EFABI was associated with a similar multiple PR (17.8% vs 17.5% in non-EFABI cases), with no triplets in EFABI patients. Live birth rates were significantly higher in EFABI cycles in IUI overall (25.5% vs 15.2%). When considered separately, the performance of EFABI resulted in significantly increased live birth rates in IUI-donor cycles (32.5% vs 18.5%), whereas the differences in IUI-husband cycles (19.5% vs 12.9%) did not reach statistical significance. The PR was 21.2% during the EFABI implementation period and 19.4% in the pre-EFABI period. Conclusions EFABI in cycles in which 4-6 follicles reach ≥14 mm is a simple option that reduces cycle cancellation rates, results in higher PRs than cycles with 1-3 follicles, and lowers the risk of multiple pregnancy.
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Affiliation(s)
- Begoña Prieto
- Human Reproduction Unit Cruces University Hospital Barakaldo Spain.,Faculty of Medicine University of the Basque Country Lejona Spain.,Biocruces Bizkaia Health Research Institute Barakaldo Spain.,Instituto Valenciano de Infertilidad (IVI) Leioa Spain
| | - Maria Diaz-Nuñez
- Human Reproduction Unit Cruces University Hospital Barakaldo Spain.,Biocruces Bizkaia Health Research Institute Barakaldo Spain
| | - Lucia Lainz
- Human Reproduction Unit Cruces University Hospital Barakaldo Spain.,Biocruces Bizkaia Health Research Institute Barakaldo Spain
| | | | - Aintzane Rabanal
- Human Reproduction Unit Cruces University Hospital Barakaldo Spain.,Faculty of Medicine University of the Basque Country Lejona Spain
| | - Maria Iglesias
- Human Reproduction Unit Cruces University Hospital Barakaldo Spain.,Biocruces Bizkaia Health Research Institute Barakaldo Spain
| | - Teresa Jauregui
- Human Reproduction Unit Cruces University Hospital Barakaldo Spain
| | | | - Ana Matorras
- European University of Madrid Villaviciosa de Odón, Madrid Spain
| | - Silvia Perez
- Biocruces Bizkaia Health Research Institute Barakaldo Spain
| | - Roberto Matorras
- Human Reproduction Unit Cruces University Hospital Barakaldo Spain.,Faculty of Medicine University of the Basque Country Lejona Spain.,Biocruces Bizkaia Health Research Institute Barakaldo Spain.,Instituto Valenciano de Infertilidad (IVI) Leioa Spain
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Danhof NA, van Wely M, Repping S, Koks C, Verhoeve HR, de Bruin JP, Verberg MFG, van Hooff MHA, Cohlen BJ, van Heteren CF, Fleischer K, Gianotten J, van Disseldorp J, Visser J, Broekmans FJM, Mol BWJ, van der Veen F, Mochtar MH. Follicle stimulating hormone versus clomiphene citrate in intrauterine insemination for unexplained subfertility: a randomized controlled trial. Hum Reprod 2019; 33:1866-1874. [PMID: 30137325 DOI: 10.1093/humrep/dey268] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 07/24/2018] [Indexed: 11/12/2022] Open
Abstract
STUDY QUESTION Is FSH or clomiphene citrate (CC) the most effective stimulation regimen in terms of ongoing pregnancies in couples with unexplained subfertility undergoing IUI with adherence to strict cancellation criteria as a measure to reduce the number of multiple pregnancies? SUMMARY ANSWER In IUI with adherence to strict cancellation criteria, ovarian stimulation with FSH is not superior to CC in terms of the cumulative ongoing pregnancy rate, and yields a similar, low multiple pregnancy rate. WHAT IS ALREADY KNOWN FSH has been shown to result in higher pregnancy rates compared to CC, but at the cost of high multiple pregnancy rates. To reduce the risk of multiple pregnancy, new ovarian stimulation regimens have been suggested, these include strict cancellation criteria to limit the number of dominant follicles per cycle i.e. withholding insemination when more than three dominant follicles develop. With such a strategy, it is unclear whether the ovarian stimulation should be done with FSH or with CC. STUDY DESIGN, SIZE, DURATION We performed an open-label multicenter randomized superiority controlled trial in the Netherlands (NTR 4057). PARTICIPANTS/MATERIALS, SETTING, METHODS We randomized couples diagnosed with unexplained subfertility and scheduled for a maximum of four cycles of IUI with ovarian stimulation with 75 IU FSH or 100 mg CC. Cycles were cancelled when more then three dominant follicles developed. The primary outcome was cumulative ongoing pregnancy rate. Multiple pregnancy was a secondary outcome. We analysed the data on intention to treat basis. We calculated relative risks and absolute risk difference with 95% CI. MAIN RESULTS AND THE ROLE OF CHANCE Between July 2013 and March 2016, we allocated 369 women to ovarian stimulation with FSH and 369 women to ovarian stimulation with CC. A total of 113 women (31%) had an ongoing pregnancy following ovarian stimulation with FSH and 97 women (26%) had an ongoing pregnancy following ovarian stimulation with CC (RR = 1.16, 95% CI: 0.93-1.47, ARD = 0.04, 95% CI: -0.02 to 0.11). Five women (1.4%) had a multiple pregnancy following ovarian stimulation with FSH and eight women (2.2%) had a multiple pregnancy following ovarian stimulation with CC (RR = 0.63, 95% CI: 0.21-1.89, ARD = -0.01, 95% CI: -0.03 to 0.01). LIMITATIONS, REASONS FOR CAUTION We were not able to blind this study due to the nature of the interventions. We consider it unlikely that this has introduced performance bias, since pregnancy outcomes are objective outcome measures. WIDER IMPLICATIONS OF THE FINDINGS We revealed that adherence to strict cancellation criteria is a successful solution to reduce the number of multiple pregnancies in IUI. To decide whether ovarian stimulation with FSH or with CC should be the regimen of choice, costs and patients' preferences should be taken into account. STUDY FUNDING/COMPETING INTEREST(S) This trial received funding from the Dutch Organization for Health Research and Development (ZonMw). Prof. Dr B.W.J. Mol is supported by a NHMRC Practitioner Fellowship (GNT1082548). B.W.M. reports consultancy for Merck, ObsEva and Guerbet. The other authors declare that they have no competing interests. TRIAL REGISTRATION NUMBER Nederlands Trial Register NTR4057. TRIAL REGISTRATION DATE 1 July 2013. DATE OF FIRST PATIENT’S ENROLMENT The first patient was randomized at 27 August 2013.
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Affiliation(s)
- N A Danhof
- Centre for Reproductive Medicine, Academic Medical Centre, Meiberg dreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - M van Wely
- Centre for Reproductive Medicine, Academic Medical Centre, Meiberg dreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - S Repping
- Centre for Reproductive Medicine, Academic Medical Centre, Meiberg dreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - C Koks
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Postbus 7777, 5500 MB, Veldhoven, The Netherlands
| | - H R Verhoeve
- Department of Obstetrics and Gynaecology, OLVG oost, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
| | - J P de Bruin
- Jeroen Bosch Hospital, Department of Obstetrics and Gynecology, Postbus 90153, 5200 ME, 's-Hertogenbosch, The Netherlands
| | - M F G Verberg
- Fertility Clinic Twente, Demmersweg 66, 7556 BN, Hengelo, The Netherlands
| | - M H A van Hooff
- Department of Obstetrics and Gynaecology, Sint Franciscus Gasthuis, Kleiweg 500, 3045 PM, Rotterdam, The Netherlands
| | - B J Cohlen
- Department of Obstetrics and Gynecology, Isala Hospital, Postbus 10400, 8000 GK, Zwolle, The Netherlands
| | - C F van Heteren
- Department of Obstetrics and Gynaecology, Canisius Wilhelmina Hospital, Postbus 9015, 6500 GS, Nijmegen, The Netherlands
| | - K Fleischer
- Centre for Reproductive Medicine, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - J Gianotten
- Department of Obstetrics and Gynaecology, Spaarne Gasthuis, Postbus 417, 2000 AK, Haarlem, The Netherlands
| | - J van Disseldorp
- Department of Obstetrics and Gynaecology, St. Antonius hospital Nieuwegein, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - J Visser
- Department of Obstetrics and Gynaecology Amphia, Postbus 90157, 4800 RL, Breda, The Netherlands
| | - F J M Broekmans
- Centre for Reproductive Medicine, University Medical Centre Utrecht, Postbus 85500, 3508 GA, Utrecht, The Netherlands
| | - B W J Mol
- Monash University, Monash Medical Centre, 246 Clayton Rd, Clayton VIC 3168, Australia
| | - F van der Veen
- Centre for Reproductive Medicine, Academic Medical Centre, Meiberg dreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - M H Mochtar
- Centre for Reproductive Medicine, Academic Medical Centre, Meiberg dreef 9, 1105 AZ, Amsterdam, The Netherlands
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Levi Setti PE, Alviggi C, Colombo GL, Pisanelli C, Ripellino C, Longobardi S, Canonico PL, De Placido G. Human recombinant follicle stimulating hormone (rFSH) compared to urinary human menopausal gonadotropin (HMG) for ovarian stimulation in assisted reproduction: a literature review and cost evaluation. J Endocrinol Invest 2015; 38:497-503. [PMID: 25480425 PMCID: PMC4555088 DOI: 10.1007/s40618-014-0204-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 10/21/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Gonadotropins are protein hormones which are central to the complex endocrine system that regulates normal growth, sexual development, and reproductive function. There is still a lively debate on which type of gonadotropin medication should be used, either human menopausal gonadotropin or recombinant follicle-stimulating hormone. The objective of the study was to perform a systematic review of the recent literature to compare recombinant follicle-stimulating hormone to human menopausal gonadotropin with the aim to assess any differences in terms of efficacy and to provide a cost evaluation based on findings of this systematic review. METHODS The review was conducted selecting prospective, randomized, controlled trials comparing the two gonadotropin medications from a literature search of several databases. The outcome measure used to evaluate efficacy was the number of oocytes retrieved per cycle. In addition, a cost evaluation was performed based on retrieved efficacy data. RESULTS The number of oocytes retrieved appeared to be higher for human menopausal gonadotropin in only 2 studies while 10 out of 13 studies showed a higher mean number of oocytes retrieved per cycle for recombinant follicle-stimulating hormone. The results of the cost evaluation provided a similar cost per oocyte for both hormones. CONCLUSIONS Recombinant follicle-stimulating hormone treatment resulted in a higher oocytes yield per cycle than human menopausal gonadotropin at similar cost per oocyte.
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Affiliation(s)
- P E Levi Setti
- Humanitas Fertility Center, Division of Gynaecology and Reproductive Medicine, Department of Gynaecology, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - C Alviggi
- Dipartimento Universitario di Neuroscienze, Scienze Riproduttive ed Odontostomatologiche, Università degli Studi di Napoli, "Federico II", Naples, Italy
| | - G L Colombo
- Department of Drug Sciences, University of Pavia, Pavia, Italy
- S.A.V.E. Studi Analisi Valutazioni Economiche, Milan, Italy
| | - C Pisanelli
- Hospital Pharmacist, ACO San Filippo Neri, Rome, Italy
- Società Italiana Di Farmacia Ospedaliera, Milan, Italy
| | - C Ripellino
- CSD Medical Research Srl, Viale Jenner n 53, 20159, Milan, Italy.
| | - S Longobardi
- Medical Department, MerckSerono S.p.A, Rome, Italy
| | - P L Canonico
- Dipartimento di Scienze del Farmaco, Università del Piemonte Orientale, Largo Donegani 2, Novara, Italy
| | - G De Placido
- University Department of Obstetrics, Gynaecology, Urology and Reproductive Medicine, University of Naples Federico II, Naples, Italy
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