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Lawrenz B, Kalafat E, Ata B, Melado L, Del Gallego R, Elkhatib I, Fatemi H. Do women with severely diminished ovarian reserve undergoing modified natural-cycle in-vitro fertilization benefit from earlier trigger at smaller follicle size? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024. [PMID: 38348612 DOI: 10.1002/uog.27611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/24/2024]
Abstract
OBJECTIVE To evaluate whether trigger and oocyte collection at a smaller follicle size decreases the risk of premature ovulation while maintaining the reproductive potential of oocytes in women with a severely diminished ovarian reserve undergoing modified natural-cycle in-vitro fertilization. METHODS This was a retrospective cohort study including women who had at least one unsuccessful cycle (due to no response) of conventional ovarian stimulation with a high dosage of gonadotropins and subsequently underwent a modified natural cycle with a solitary growing follicle (i.e. only one follicle > 10 mm at the time of trigger). The association between follicle size at trigger and various cycle outcomes was tested using regression analyses. RESULTS A total of 160 ovarian stimulation cycles from 110 patients were included in the analysis. Oocyte pick-up (OPU) was performed in 153 cycles and 7 cycles were canceled due to premature ovulation. Patients who received their trigger at smaller follicle sizes (≤ 15 mm) had significantly lower rates of premature ovulation and thus higher rates of OPU (98.9% vs 90.8%; odds ratio, 9.56 (95% CI, 1.58-182.9); P = 0.039) compared with those who received their trigger at larger follicle sizes (> 15 mm). On multivariable analysis, smaller follicle sizes at trigger (> 10 to 13 mm, > 13 to 15 mm, > 15 mm to 17 mm) were not associated significantly with a lower rate of cumulus-oocyte complex (COC) retrieval, metaphase-II (MII) oocytes or blastulation when compared to the > 17-mm group. On sensitivity analysis including only the first cycle of each couple, the maturity rate among those with COC retrieval was highest in follicle sizes > 15 to 17 mm (92.3%) and > 13 to 15 mm (91.7%), followed by > 10 to 13 mm (85.7%) and lowest in the > 17-mm group (58.8%). During the study period, five euploid blastocysts developed from 48 fertilized MII oocytes with follicle sizes of 12 mm (n = 3), 14 mm (n = 1) and 16 mm (n = 1) at trigger. Of those, four were transferred and resulted in two live births, both of which developed from follicles with a size at trigger of 12 mm. CONCLUSIONS The ideal follicle size for triggering oocyte maturation may be smaller in women with a severely diminished ovarian reserve managed on a modified natural cycle when compared to conventional cut-offs. The risk of OPU cancellation was significantly higher in women triggered at follicle size > 15 mm and the yield of mature oocytes was not adversely affected in women triggered at follicle size > 13 to 15 mm compared with > 15 to 17 mm. Waiting for follicles to reach sizes > 17mm may be detrimental to achieving optimal outcome. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- B Lawrenz
- ART Fertility Clinic, Royal Marina Village, Abu Dhabi, United Arab Emirates
- Department of Reproductive Medicine, UZ Ghent, Ghent, Belgium
| | - E Kalafat
- ART Fertility Clinic, Royal Marina Village, Abu Dhabi, United Arab Emirates
- Faculty of Medicine, Department of Obstetrics and Gynecology, Koc University, Istanbul, Turkey
| | - B Ata
- Faculty of Medicine, Department of Obstetrics and Gynecology, Koc University, Istanbul, Turkey
- ART Fertility Clinic, Umm Suqeim, Dubai, United Arab Emirates
| | - L Melado
- ART Fertility Clinic, Royal Marina Village, Abu Dhabi, United Arab Emirates
| | - R Del Gallego
- ART Fertility Clinic, Royal Marina Village, Abu Dhabi, United Arab Emirates
| | - I Elkhatib
- ART Fertility Clinic, Royal Marina Village, Abu Dhabi, United Arab Emirates
- School of Biosciences, University of Kent, Canterbury, UK
| | - H Fatemi
- ART Fertility Clinic, Royal Marina Village, Abu Dhabi, United Arab Emirates
- ART Fertility Clinic, Umm Suqeim, Dubai, United Arab Emirates
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Reuvenny S, Youngster M, Luz A, Hourvitz R, Maman E, Baum M, Hourvitz A. An artificial intelligence-based approach for selecting the optimal day for triggering in antagonist protocol cycles. Reprod Biomed Online 2024; 48:103423. [PMID: 37984005 DOI: 10.1016/j.rbmo.2023.103423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/06/2023] [Accepted: 09/22/2023] [Indexed: 11/22/2023]
Abstract
RESEARCH QUESTION Can a machine-learning model suggest an optimal trigger day (or days), analysing three consecutive days, to maximize the number of total and mature (metaphase II [MII]) oocytes retrieved during an antagonist protocol cycle? DESIGN This retrospective cohort study included 9622 antagonist cycles between 2018 and 2022. The dataset was divided into training, validation and test sets. An XGBoost machine-learning algorithm, based on the cycles' data, suggested optimal trigger days for maximizing the number of MII oocytes retrieved by considering the MII predictions, prediction errors and outlier detection results. Evaluation of the algorithm was conducted using a test dataset including three quality groups: 'Freeze-all oocytes', 'Fertilize-all' and 'ICSI-only' cycles. The model suggested 1, 2 or 3 days as trigger options, depending on the difference in potential outcomes. The suggested days were compared with the actual trigger day chosen by the physician and were labelled 'concordant' or 'discordant' in terms of agreement. RESULTS In the 'freeze-all' test-set, the concordant group showed an average increase of 4.8 oocytes and 3.4 MII oocytes. In the 'ICSI-only' test set there was an average increase of 3.8 MII oocytes and 1.1 embryos, and in the 'fertilize-all' test set an average increase of 3.6 oocytes and 0.9 embryos was observed (P < 0.001 for all parameters in all groups). CONCLUSIONS Utilizing a machine-learning model for determining the optimal trigger days may improve antagonist protocol cycle outcomes across all age groups in freeze-all or fresh transfer cycles. Implementation of these models may more accurately predict the number of oocytes retrieved, thus optimizing physicians' decisions, balancing workloads and creating more standardized, yet patient-specific, protocols.
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Affiliation(s)
| | - Michal Youngster
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel.; IVF Unit, Department of Obstetrics and Gynecology, Shamir Medical Center, Zerifin, Israel..
| | | | | | - Ettie Maman
- FertilAI, Ramat-Gan, Israel.; Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel.; IVF Unit, Herzliya Medical Centre, Herzliya, Israel.; IVF Unit, Department of Obstetrics and Gynecology, Sheba Medical Centre, Ramat-Gan, Israel
| | - Micha Baum
- FertilAI, Ramat-Gan, Israel.; Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel.; IVF Unit, Herzliya Medical Centre, Herzliya, Israel.; IVF Unit, Department of Obstetrics and Gynecology, Sheba Medical Centre, Ramat-Gan, Israel
| | - Ariel Hourvitz
- FertilAI, Ramat-Gan, Israel.; Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel.; IVF Unit, Department of Obstetrics and Gynecology, Shamir Medical Center, Zerifin, Israel
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Su H, Lai Y, Li J, Liao T, Ji L, Hu X, Qian K. Increasing dominant follicular proportion negatively associated with good clinical outcomes in normal ovarian responders using the depot GnRH agonist protocol: a large-sample retrospective analysis. J Ovarian Res 2022; 15:44. [PMID: 35418089 PMCID: PMC9006398 DOI: 10.1186/s13048-022-00973-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 03/26/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Currently, there is no universal criteria for the trigger time of controlled ovarian hyperstimulation (COH), especially with the emerging depot GnRH agonist protocol. It is challenging to explore an indicator that is representative of target follicle cohort development as an alternative to the conventional approach of determining the trigger time based on a few leading follicles. METHODS This was a large-sample retrospective analysis. Between January 2016 and January 2020, 1,925 young normal ovarian responders who underwent their first in vitro fertilisation (IVF)/intracytoplasmic sperm injection (ICSI) cycle using the depot GnRH agonist protocol were included. They were divided into three groups based on the dominant follicular proportion (DFP, defined as the ratio of ≥ 18 mm dominant follicles/ ≥ 14 mm large follicles on the human chorionic gonadotropin (HCG) day; Group A: < 30%; Group B: 30%-60%; and Group C: ≥ 60%). The binary logistic regression and multivariate linear regression were used to assess whether the DFP was associated with clinical pregnancy, the number of frozen blastocysts, the blastocyst formation rate, and the low number of frozen blastocysts. RESULTS The logistic regression analysis showed that compared with Group A, the odds ratio (OR) for clinical pregnancy was 1.345 in Group B (P = 0.023), and there was no statistical difference between Group C and Group A (P = 0.216). The multivariate linear regression analysis showed that DFP was negatively associated with the number of frozen blastocysts (β ± SE: Group B vs. Group A = - 0.319 ± 0.115, P = 0.006; Group C vs. Group A = - 0.432 ± 0.154, P = 0.005) as well as the blastocyst formation rate (β ± SE: Group B vs. Group A = - 0.035 ± 0.016, P = 0.031; Group C vs. Group A = - 0.039 ± 0.021, P = 0.067). Furthermore, the OR for the low number of frozen blastocysts was 1.312 in Group B (P = 0.039) and 1.417 in Group C (P = 0.041) compared to Group A. CONCLUSIONS For young normal ovarian responders using the depot GnRH agonist protocol, increasing DFP might reduce the developmental potential of oocytes and reduce the number of available blastocysts, and this might result in a lower cumulative pregnancy rate. However, further confirmation using strict prospective randomised controlled studies is required.
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Affiliation(s)
- Houming Su
- grid.33199.310000 0004 0368 7223Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Youhua Lai
- grid.33199.310000 0004 0368 7223Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jie Li
- grid.33199.310000 0004 0368 7223Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tingting Liao
- grid.33199.310000 0004 0368 7223Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Licheng Ji
- grid.33199.310000 0004 0368 7223Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xinyao Hu
- grid.33199.310000 0004 0368 7223Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kun Qian
- grid.33199.310000 0004 0368 7223Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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The different impact of stimulation duration on oocyte maturation and pregnancy outcome in fresh cycles with GnRH antagonist protocol in poor responders and normal responders. Taiwan J Obstet Gynecol 2020; 58:471-476. [PMID: 31307735 DOI: 10.1016/j.tjog.2019.05.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2019] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To study the impact of stimulation duration on intracytoplasmic sperm injection (ICSI) - embryo transfer (ET) outcome in poor and normal responders during controlled ovarian stimulation using gonadotropin-releasing hormone (GnRH) antagonist protocol. MATERIALS AND METHODS This is a retrospective cohort study. There were 1481 women undergoing ICSI-ET cycles. Women with ovum pick-up number ≤3 were defined as poor responders (n = 235), and those with a number ≥4 were normal responders (n = 1246). RESULTS The mean stimulation duration was shorter in poor responders with pregnancy group as compared with normal responders with pregnancy group (7.8 ± 2.2 vs. 9.2 ± 1.6 days, p < 0.01). Poor responders with a shortest stimulation duration (≤6 days) appeared a higher live birth rate (≤6 days: 33.3%, 7-8 days: 20.0%, 9-10 days: 15.9%, and ≥11 days: 11.1%, p = 0.18). Normal responders with a shortest stimulation duration (≤6 days) appeared a lowest live birth rate (≤6 days: 28.6%, 7-8 days: 35.8%, 9-10 days: 33.6%, and ≥11 days: 29.3%, p = 0.61). Oocyte maturation rate was significantly lower at stimulation durations ≤6 days group (≤6 days: 67%, 7-8 days: 80%, 9-10 days: 85%, and ≥11 days: 87%, p = 0.02) in normal responders. CONCLUSION In ICSI-ET cycles, stimulation duration appears to have different impact on oocyte maturation, clinical pregnancy rates and live birth rates in both poor and normal responders.
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Abbara A, Clarke SA, Dhillo WS. Novel Concepts for Inducing Final Oocyte Maturation in In Vitro Fertilization Treatment. Endocr Rev 2018; 39:593-628. [PMID: 29982525 PMCID: PMC6173475 DOI: 10.1210/er.2017-00236] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 06/27/2018] [Indexed: 01/20/2023]
Abstract
Infertility affects one in six of the population and increasingly couples require treatment with assisted reproductive techniques. In vitro fertilization (IVF) treatment is most commonly conducted using exogenous FSH to induce follicular growth and human chorionic gonadotropin (hCG) to induce final oocyte maturation. However, hCG may cause the potentially life-threatening iatrogenic complication "ovarian hyperstimulation syndrome" (OHSS), which can cause considerable morbidity and, rarely, even mortality in otherwise healthy women. The use of GnRH agonists (GnRHas) has been pioneered during the last two decades to provide a safer option to induce final oocyte maturation. More recently, the neuropeptide kisspeptin, a hypothalamic regulator of GnRH release, has been investigated as a novel inductor of oocyte maturation. The hormonal stimulus used to induce oocyte maturation has a major impact on the success (retrieval of oocytes and chance of implantation) and safety (risk of OHSS) of IVF treatment. This review aims to appraise experimental and clinical data of hormonal approaches used to induce final oocyte maturation by hCG, GnRHa, both GnRHa and hCG administered in combination, recombinant LH, or kisspeptin. We also examine evidence for the timing of administration of the inductor of final oocyte maturation in relationship to parameters of follicular growth and the subsequent interval to oocyte retrieval. In summary, we review data on the efficacy and safety of the major hormonal approaches used to induce final oocyte maturation in clinical practice, as well as some novel approaches that may offer fresh alternatives in future.
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Affiliation(s)
- Ali Abbara
- Department of Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Sophie A Clarke
- Department of Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Waljit S Dhillo
- Department of Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
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6
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Wu YG, Barad DH, Kushnir VA, Wang Q, Zhang L, Darmon SK, Albertini DF, Gleicher N. With low ovarian reserve, Highly Individualized Egg Retrieval (HIER) improves IVF results by avoiding premature luteinization. J Ovarian Res 2018; 11:23. [PMID: 29548330 PMCID: PMC5857093 DOI: 10.1186/s13048-018-0398-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 03/13/2018] [Indexed: 01/06/2023] Open
Abstract
Background Highly Individualized Egg Retrieval (HIER), defined as age-specific early oocyte retrieval (ER), has been demonstrated to avoid premature luteinization in women ≥43. We here investigated whether HIER also applies to younger women with premature ovarian aging (POA), and what best lead follicle size should be for administration of ovulation-triggers. Methods Fifty-six women ≥43, and 37 POA patients underwent IVF cycles. Granulosa cells (GCs) were isolated, cultures were established, RNA was extracted and real-time PCR analyses performed, with gene expressions at mRNA level investigated for FSH receptor (FSHR), luteinizing hormone receptor (LHCPR), P450 aromatase (CYP19a1) and progesterone receptor (PGR). POA was defined by age < 40, FSH above 95%CI and/or AMH below 95%CI for age. Women ≥43 years were divided into very early retrieval (VER), with human chorionic gonadotropin (hCG) trigger at 13.5–15.5 mm, ER at 16.0–18.0 mm or standard retrievel (SR) at 18.5–20.5 mm; POA patients were divided into ER and SR. Pregnancy rates and and molecular markers of premature luteinization (PL) were main outcome measures. Results ER resulted in a significantly higher clinical pregnancy rate (16.7%) than VER (5.9%) or SR (6.7%; both P < 0.05). Molecular markers of PL were highest with SR and lowest with VER. In POA, ER improved pregnancy chances even more than in women ≥43 (7.7% with SR vs. 41.7% with ER), while also reducing molecular markers of PL. With low ovarian reserve (LOR), by avoiding PL, ER with hCG trigger at 16.0–18.0 mm, thus, improves clinical pregnancy rates at all ages. As VER demonstrated lowest molecular PL marker but equally poor pregnancy rates as SR, too early ovulation triggers, likely, result in cytoplasmatic immaturity. Conclusions HIER is even more effective in POA patients than women above age 43, demonstrating that HIER should be further investigated going into even more advanced ages.
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Affiliation(s)
- Yan-Guang Wu
- The Center for Human Reproduction, New York, NY, 10021, USA
| | - David H Barad
- The Center for Human Reproduction, New York, NY, 10021, USA.,The Foundation for Reproductive Medicine, New York, NY, 10021, USA
| | - Vitaly A Kushnir
- The Center for Human Reproduction, New York, NY, 10021, USA.,Department of Obstetrics and Gynecology, Wake Forest University, Winston Salem, NC, 27106, USA
| | - Qi Wang
- The Center for Human Reproduction, New York, NY, 10021, USA
| | - Lin Zhang
- The Center for Human Reproduction, New York, NY, 10021, USA
| | - Sarah K Darmon
- The Center for Human Reproduction, New York, NY, 10021, USA
| | - David F Albertini
- The Center for Human Reproduction, New York, NY, 10021, USA.,Stem Cell Biology and Molecular Embryology Laboratory, The Rockefeller University, New York, NY, 10065, USA
| | - Norbert Gleicher
- The Center for Human Reproduction, New York, NY, 10021, USA. .,The Foundation for Reproductive Medicine, New York, NY, 10021, USA. .,Stem Cell Biology and Molecular Embryology Laboratory, The Rockefeller University, New York, NY, 10065, USA. .,Department of Obstetics and Gynecology, University of Vienna School of Medicine, 1090, Vienna, Austria.
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Abbara A, Vuong LN, Ho VNA, Clarke SA, Jeffers L, Comninos AN, Salim R, Ho TM, Kelsey TW, Trew GH, Humaidan P, Dhillo WS. Follicle Size on Day of Trigger Most Likely to Yield a Mature Oocyte. Front Endocrinol (Lausanne) 2018; 9:193. [PMID: 29743877 PMCID: PMC5930292 DOI: 10.3389/fendo.2018.00193] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 04/09/2018] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To identify follicle sizes on the day of trigger most likely to yield a mature oocyte following hCG, GnRH agonist (GnRHa), or kisspeptin during IVF treatment. DESIGN Retrospective analysis to determine the size of follicles on day of trigger contributing most to the number of mature oocytes retrieved using generalized linear regression and random forest models applied to data from IVF cycles (2014-2017) in which either hCG, GnRHa, or kisspeptin trigger was used. SETTING HCG and GnRHa data were collected at My Duc Hospital, Ho Chi Minh City, Vietnam, and kisspeptin data were collected at Hammersmith Hospital, London, UK. PATIENTS Four hundred and forty nine women aged 18-38 years with antral follicle counts 4-87 were triggered with hCG (n = 161), GnRHa (n = 165), or kisspeptin (n = 173). MAIN OUTCOME MEASURE Follicle sizes on the day of trigger most likely to yield a mature oocyte. RESULTS Follicles 12-19 mm on the day of trigger contributed the most to the number of oocytes and mature oocytes retrieved. Comparing the tertile of patients with the highest proportion of follicles on the day of trigger 12-19 mm, with the tertile of patients with the lowest proportion within this size range, revealed increases of 4.7 mature oocytes for hCG (P < 0.0001) and 4.9 mature oocytes for GnRHa triggering (P < 0.01). Using simulated follicle size profiles of patients with 20 follicles on the day of trigger, our model predicts that the number of oocytes retrieved would increase from a mean 9.8 (95% prediction limit 9.3-10.3) to 14.8 (95% prediction limit 13.3-16.3) oocytes due to the difference in follicle size profile alone. CONCLUSION Follicles 12-19 mm on the morning of trigger administration were most likely to yield a mature oocyte following hCG, GnRHa, or kisspeptin.
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Affiliation(s)
- Ali Abbara
- Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Lan N. Vuong
- University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
- IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam
| | - Vu N. A. Ho
- IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam
| | - Sophie A. Clarke
- Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Lisa Jeffers
- Imperial College London, Hammersmith Hospital, London, United Kingdom
| | | | - Rehan Salim
- IVF Unit, Hammersmith Hospital, London, United Kingdom
| | - Tuong M. Ho
- IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam
| | - Tom W. Kelsey
- School of Computer Science, University of St Andrews, St Andrews, United Kingdom
| | | | - Peter Humaidan
- The Fertility Clinic, Skive Regional Hospital, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Waljit S. Dhillo
- Imperial College London, Hammersmith Hospital, London, United Kingdom
- *Correspondence: Waljit S. Dhillo,
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Feichtinger M, Karlström PO, Olofsson JI, Rodriguez-Wallberg KA. Weekend-free scheduled IVF/ICSI procedures and single embryo transfer do not reduce live-birth rates in a general infertile population. Acta Obstet Gynecol Scand 2017; 96:1423-1429. [PMID: 28940191 PMCID: PMC6055597 DOI: 10.1111/aogs.13235] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 09/17/2017] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Scheduling of ovum pickup only on weekdays may result in cases of apparently suboptimal timing for human chorionic gonadotropin and ovum pickup. This study aimed to assess whether live-birth rates were reduced in women with a potentially suboptimal day for human chorionic gonadotropin and ovum pickup to avoid weekend work, according to ultrasonographic data on the day of human chorionic gonadotropin planning. MATERIAL AND METHODS An evaluation of the optimal human chorionic gonadotropin priming date was performed in treatment protocols of 1000 consecutive patients undergoing their first in vitro fertilization/intracytoplasmatic sperm injection with single-embryo transfer. An ideal ovum pickup day was characterized by human chorionic gonadotropin-scheduling when three or more follicles reached 17 mm (day 0) or with one day of delay (day +1) (n = 760). A non-ideal ovum pickup was either early (day -1, -2, -3) (n = 24) or delayed (day +2, +3, +4) (n = 216). Live-birth rates in the ideal and non-ideal ovum pickup groups was set as primary outcome measure. RESULTS Early-ovum pickups were excluded as they were infrequent. No differences between ideal and delayed ovum pickup groups were found regarding number of oocytes retrieved (9.87 vs. 9.78, p = 0.990), pregnancy rates (28.3% vs. 29.6%, p = 0.701) or live-birth rates (26.2% vs. 25.9%, p = 0.939). However, sub analyses indicated that treatment with gonadotropin releasing hormone antagonists resulted in significantly lower clinical pregnancy rates in delayed ovum pickups (odds ratio 0.46, p = 0.014), compared with agonist treatments. CONCLUSIONS Weekend work may not be needed for in vitro fertilization/intracytoplasmatic sperm injection single-embryo transfer treatments. However, in gonadotropin releasing hormone antagonist cycles, delaying ovum pickup more than one day may result in unfavorable outcomes.
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Affiliation(s)
- Michael Feichtinger
- Reproductive Medicine, Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden.,Department of Obstetrics and Gynecology, Division of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, Vienna, Austria.,Wunschbaby Institute Feichtinger, Vienna, Austria
| | - Per O Karlström
- Reproductive Medicine, Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - Jan I Olofsson
- Reproductive Medicine, Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden.,Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Kenny A Rodriguez-Wallberg
- Reproductive Medicine, Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden.,Department of Oncology - Pathology, Karolinska Institute, Stockholm, Sweden
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9
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Davar R, Naghshineh E, Neghab N. The effect of 24 hours delay in oocyte maturation triggering in IVF/ICSI cycles with antagonist protocol and not-elevated progesterone: A randomized control trial. Int J Reprod Biomed 2017. [DOI: 10.29252/ijrm.15.7.441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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10
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Cissen M, Bensdorp A, Cohlen BJ, Repping S, de Bruin JP, van Wely M. Assisted reproductive technologies for male subfertility. Cochrane Database Syst Rev 2016; 2:CD000360. [PMID: 26915339 DOI: 10.1002/14651858.cd000360.pub5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Intra-uterine insemination (IUI), in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI) are frequently used fertility treatments for couples with male subfertility. The use of these treatments has been subject of discussion. Knowledge on the effectiveness of fertility treatments for male subfertility with different grades of severity is limited. Possibly, couples are exposed to unnecessary or ineffective treatments on a large scale. OBJECTIVES To evaluate the effectiveness and safety of different fertility treatments (expectant management, timed intercourse (TI), IUI, IVF and ICSI) for couples whose subfertility appears to be due to abnormal sperm parameters. SEARCH METHODS We searched for all publications that described randomised controlled trials (RCTs) of the treatment for male subfertility. We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, PsycINFO and the National Research Register from inception to 14 April 2015, and web-based trial registers from January 1985 to April 2015. We applied no language restrictions. We checked all references in the identified trials and background papers and contacted authors to identify relevant published and unpublished data. SELECTION CRITERIA We included RCTs comparing different treatment options for male subfertility. These were expectant management, TI (with or without ovarian hyperstimulation (OH)), IUI (with or without OH), IVF and ICSI. We included only couples with abnormal sperm parameters. DATA COLLECTION AND ANALYSIS Two review authors independently selected the studies, extracted data and assessed risk of bias. They resolved disagreements by discussion with the rest of the review authors. We performed statistical analyses in accordance with the guidelines for statistical analysis developed by The Cochrane Collaboration. The quality of the evidence was rated using the GRADE methods. Primary outcomes were live birth and ovarian hyperstimulation syndrome (OHSS) per couple randomised. MAIN RESULTS The review included 10 RCTs (757 couples). The quality of the evidence was low or very low for all comparisons. The main limitations in the evidence were failure to describe study methods, serious imprecision and inconsistency. IUI versus TI (five RCTs)Two RCTs compared IUI with TI in natural cycles. There were no data on live birth or OHSS. We found no evidence of a difference in pregnancy rates (2 RCTs, 62 couples: odds ratio (OR) 4.57, 95% confidence interval (CI) 0.21 to 102, very low quality evidence; there were no events in one of the studies).Three RCTs compared IUI with TI both in cycles with OH. We found no evidence of a difference in live birth rates (1 RCT, 81 couples: OR 0.89, 95% CI 0.30 to 2.59; low quality evidence) or pregnancy rates (3 RCTs, 202 couples: OR 1.51, 95% CI 0.74 to 3.07; I(2) = 11%, very low quality evidence). One RCT reported data on OHSS. None of the 62 women had OHSS.One RCT compared IUI in cycles with OH with TI in natural cycles. We found no evidence of a difference in live birth rates (1 RCT, 44 couples: OR 3.14, 95% CI 0.12 to 81.35; very low quality evidence). Data on OHSS were not available. IUI in cycles with OH versus IUI in natural cycles (five RCTs)We found no evidence of a difference in live birth rates (3 RCTs, 346 couples: OR 1.34, 95% CI 0.77 to 2.33; I(2) = 0%, very low quality evidence) and pregnancy rates (4 RCTs, 399 couples: OR 1.68, 95% CI 1.00 to 2.82; I(2) = 0%, very low quality evidence). There were no data on OHSS. IVF versus IUI in natural cycles or cycles with OH (two RCTs)We found no evidence of a difference in live birth rates between IVF versus IUI in natural cycles (1 RCT, 53 couples: OR 0.77, 95% CI 0.25 to 2.35; low quality evidence) or IVF versus IUI in cycles with OH (2 RCTs, 86 couples: OR 1.03, 95% CI 0.43 to 2.45; I(2) = 0%, very low quality evidence). One RCT reported data on OHSS. None of the women had OHSS.Overall, we found no evidence of a difference between any of the groups in rates of live birth, pregnancy or adverse events (multiple pregnancy, miscarriage). However, most of the evidence was very low quality.There were no studies on IUI in natural cycles versus TI in stimulated cycles, IVF versus TI, ICSI versus TI, ICSI versus IUI (with OH) or ICSI versus IVF. AUTHORS' CONCLUSIONS We found insufficient evidence to determine whether there was any difference in safety and effectiveness between different treatments for male subfertility. More research is needed.
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Affiliation(s)
- Maartje Cissen
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, Henri Dunantstraat 1, PO Box 90153, 's-Hertogenbosch, Netherlands, 5200 ME
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Blockeel C, Drakopoulos P, Santos-Ribeiro S, Polyzos NP, Tournaye H. A fresh look at the freeze-all protocol: a SWOT analysis. Hum Reprod 2016; 31:491-7. [PMID: 26724793 DOI: 10.1093/humrep/dev339] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 12/16/2015] [Indexed: 11/14/2022] Open
Abstract
The 'freeze-all' strategy with the segmentation of IVF treatment, namely with the use of a GnRH antagonist protocol, GnRH agonist triggering, the elective cryopreservation of all embryos by vitrification and a frozen-thawed embryo transfer in a subsequent cycle, has become more popular. However, the approach still encounters drawbacks. In this opinion paper, a SWOT (strengths, weaknesses, opportunities and threats) analysis sheds light on the different aspects of this strategy.
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Affiliation(s)
- Christophe Blockeel
- Centre for Reproductive Medicine, UZ Brussel, Laarbeeklaan 101, 1090 Jette, Belgium
| | | | | | - Nikolaos P Polyzos
- Centre for Reproductive Medicine, UZ Brussel, Laarbeeklaan 101, 1090 Jette, Belgium
| | - Herman Tournaye
- Centre for Reproductive Medicine, UZ Brussel, Laarbeeklaan 101, 1090 Jette, Belgium
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Siristatidis CS, Gibreel A, Basios G, Maheshwari A, Bhattacharya S. Gonadotrophin-releasing hormone agonist protocols for pituitary suppression in assisted reproduction. Cochrane Database Syst Rev 2015; 2015:CD006919. [PMID: 26558801 PMCID: PMC10759000 DOI: 10.1002/14651858.cd006919.pub4] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Gonadotrophin-releasing hormone agonists (GnRHa) are commonly used in assisted reproduction technology (ART) cycles to prevent a luteinising hormone surge during controlled ovarian hyperstimulation (COH) prior to planned oocyte retrieval, thus optimising the chances of live birth. OBJECTIVES To evaluate the effectiveness of the different GnRHa protocols as adjuncts to COH in women undergoing ART cycles. SEARCH METHODS We searched the following databases from inception to April 2015: the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library (2015, Issue 3), MEDLINE, EMBASE, CINAHL, PsycINFO, and registries of ongoing trials. Reference lists of relevant articles were also searched. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing any two protocols of GnRHa used in in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) cycles in subfertile women. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, assessed trial eligibility and risk of bias, and extracted the data. The primary outcome measure was number of live births or ongoing pregnancies per woman/couple randomised. Secondary outcome measures were number of clinical pregnancies, number of oocytes retrieved, dose of gonadotrophins used, adverse effects (pregnancy losses, ovarian hyperstimulation, cycle cancellation, and premature luteinising hormone (LH) surges), and cost and acceptability of the regimens. We combined data to calculate odds ratios (OR) for dichotomous variables and mean differences (MD) for continuous variables, with 95% confidence intervals (CIs). We assessed statistical heterogeneity using the I² statistic. We assessed the overall quality of the evidence for the main comparisons using 'Grading of Recommendations Assessment, Development and Evaluation' (GRADE) methods. MAIN RESULTS We included 37 RCTs (3872 women), one ongoing trial, and one trial awaiting classification. These trials made nine different comparisons between protocols. Twenty of the RCTs compared long protocols and short protocols. Only 19/37 RCTs reported live birth or ongoing pregnancy.There was no conclusive evidence of a difference between a long protocol and a short protocol in live birth and ongoing pregnancy rates (OR 1.30, 95% CI 0.94 to 1.81; 12 RCTs, n = 976 women, I² = 15%, low quality evidence). Our findings suggest that in a population in which 14% of women achieve live birth or ongoing pregnancy using a short protocol, between 13% and 23% will achieve live birth or ongoing pregnancy using a long protocol. There was evidence of an increase in clinical pregnancy rates (OR 1.50, 95% CI 1.18 to 1.92; 20 RCTs, n = 1643 women, I² = 27%, moderate quality evidence) associated with the use of a long protocol.There was no evidence of a difference between the groups in terms of live birth and ongoing pregnancy rates when the following GnRHa protocols were compared: long versus ultrashort protocol (OR 1.78, 95% CI 0.72 to 4.36; one RCT, n = 150 women, low quality evidence), long luteal versus long follicular phase protocol (OR 1.89, 95% CI 0.87 to 4.10; one RCT, n = 223 women, low quality evidence), when GnRHa was stopped versus when it was continued (OR 0.75, 95% CI 0.42 to 1.33; three RCTs, n = 290 women, I² = 0%, low quality evidence), when the dose of GnRHa was reduced versus when the same dose was continued (OR 1.02, 95% CI 0.68 to 1.52; four RCTs, n = 407 women, I² = 0%, low quality evidence), when GnRHa was discontinued versus continued after human chorionic gonadotrophin (HCG) administration in the long protocol (OR 0.89, 95% CI 0.49 to 1.64; one RCT, n = 181 women, low quality evidence), and when administration of GnRHa lasted for two versus three weeks before stimulation (OR 1.14, 95% CI 0.49 to 2.68; one RCT, n = 85 women, low quality evidence). Our primary outcomes were not reported for any other comparisons.Regarding adverse events, there were insufficient data to enable us to reach any conclusions except about the cycle cancellation rate. There was no conclusive evidence of a difference in cycle cancellation rate (OR 0.95, 95% CI 0.59 to 1.55; 11 RCTs, n = 1026 women, I² = 42%, low quality evidence) when a long protocol was compared with a short protocol. This suggests that in a population in which 9% of women would have their cycles cancelled using a short protocol, between 5.5% and 14% will have cancelled cycles when using a long protocol.The quality of the evidence ranged from moderate to low. The main limitations in the evidence were failure to report live birth or ongoing pregnancy, poor reporting of methods in the primary studies, and imprecise findings due to lack of data. Only 10 of the 37 included studies were conducted within the last 10 years. AUTHORS' CONCLUSIONS When long GnRHa protocols and short GnRHa protocols were compared, we found no conclusive evidence of a difference in live birth and ongoing pregnancy rates, but there was moderate quality evidence of higher clinical pregnancy rates in the long protocol group. None of the other analyses showed any evidence of a difference in birth or pregnancy outcomes between the protocols compared. There was insufficient evidence to make any conclusions regarding adverse effects.
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Affiliation(s)
- Charalampos S Siristatidis
- University of AthensAssisted Reproduction Unit, 3rd Department of Obstetrics and GynaecologyAttikon University Hospital,Rimini 1AthensChaidariGreece12462
| | - Ahmed Gibreel
- Faculty of Medicine, Mansoura UniversityObstetrics & GynaecologyMansouraEgypt
| | - George Basios
- University of AthensAssisted Reproduction Unit, 3rd Department of Obstetrics and GynaecologyAttikon University Hospital,Rimini 1AthensChaidariGreece12462
| | - Abha Maheshwari
- University of AberdeenDivision of Applied Health SciencesAberdeenUKAB25 2ZL
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Chen Y, Zhang Y, Hu M, Liu X, Qi H. Timing of human chorionic gonadotropin (hCG) hormone administration in IVF/ICSI protocols using GnRH agonist or antagonists: a systematic review and meta-analysis. Gynecol Endocrinol 2014; 30:431-7. [PMID: 24731070 DOI: 10.3109/09513590.2014.895984] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To evaluate the effect of altering the timing of human chorionic gonadotropin (hCG) administration on the clinical outcome of in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) using gonadotropic hormone releasing hormone (GnRH) agonist or antagonist. METHODS We systematically searched six databases. Randomized controlled trials (RCTs) of the effects of altering the timing of hCG administration on the clinical outcome of IVF and ICSI using GnRH agonist or antagonist were included. A meta-analysis was conducted following a quality evaluation performed with Cochrane Collaboration's Review Manager (RevMan) 5.0.2. RESULTS Seven RCTs and a total of 1295 participants were included. Significant difference was observed regarding estradiol and progesterone levels on the day of hCG administration and oocyte retrieval between early hCG and late hCG administration group and in favor of the latter. The fertilization rate was not statistically different between early and 24-h late hCG groups, but it is significantly higher in the 48-h late hCG group. The pooled results showed no significant differences in the ongoing pregnancy rate per oocyte pick-up, the miscarriage rate and the live birth rate. CONCLUSION The prolongation of follicular phase by delaying hCG administration could increase estradiol, progesterone levels and oocyte retrieval, which will not influence ongoing pregnancy rate per oocyte pick-up, miscarriage rate and live birth rate. Postponing hCG may enable increased flexibility of cycle scheduling to avoid weekend procedures.
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Affiliation(s)
- Ying Chen
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University , Chongqing , P.R. China and
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Vandekerckhove F, Gerris J, Vansteelandt S, De Baerdemaeker A, Tilleman K, De Sutter P. Delaying the oocyte maturation trigger by one day leads to a higher metaphase II oocyte yield in IVF/ICSI: a randomised controlled trial. Reprod Biol Endocrinol 2014; 12:31. [PMID: 24758641 PMCID: PMC4008411 DOI: 10.1186/1477-7827-12-31] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 04/17/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The negative impact of rising progesterone levels on pregnancy rates is well known, but data on mature oocyte yield are conflicting. We examined whether delaying the oocyte maturation trigger in IVF/ICSI affected the number of mature oocytes and investigated the potential influence of serum progesterone levels in this process. METHODS Between January 31, 2011, and December 31, 2011, 262 consecutive patients were monitored using ultrasound plus hormonal evaluation. Those with > =3 follicles with a mean diameter of > =18 mm were divided into 2 groups depending on their serum progesterone levels. In cases with a progesterone level < = 1 ng/ml, which was observed in 59 patients, 30-50% of their total number of follicles (only counting those larger than 10 mm) were at least 18 mm in diameter. These patients were randomised into 2 groups: in one group, final oocyte maturation was triggered the same day; for the other, maturation was triggered 24 hours later. Seventy-two patients with progesterone levels > 1 ng/ml were randomised in the same manner, irrespective of the percentage of larger follicles (> = 18 mm). The number of metaphase II oocytes was our primary outcome variable. Because some patients were included more than once, correction for duplicate patients was performed. RESULTS In the study arm with low progesterone (<= 1 ng/ml), the mean number of metaphase II oocytes (+/-SD) was 10.29 (+/-6.35) in the group with delayed administration of the oocyte maturation trigger versus 7.64 (+/-3.26) in the control group. After adjusting for age, the mean difference was 2.41 (95% CI: 0.22-4.61; p = 0.031). In the study arm with elevated progesterone (>1 ng/ml), the mean numbers of metaphase II oocytes (+/-SD) were 11.81 (+/-9.91) and 12.03 (+/-7.09) for the delayed and control groups, respectively. After adjusting for PCOS (polycystic ovary syndrome) and female pathology, the mean difference was -0.44 (95% CI: -3.65-2.78; p = 0.79). CONCLUSIONS Delaying oocyte maturation in patients with low progesterone levels yields greater numbers of mature oocytes.
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Affiliation(s)
- Frank Vandekerckhove
- Centre for Reproductive Medicine, University Hospital Ghent, De Pintelaan 185, Gent 9000, Belgium
| | - Jan Gerris
- Centre for Reproductive Medicine, University Hospital Ghent, De Pintelaan 185, Gent 9000, Belgium
| | - Stijn Vansteelandt
- Department of Applied Mathematics, Computer Science and Statistics, Ghent University, Krijgslaan 281 S9, Gent 9000, Belgium
| | - An De Baerdemaeker
- Centre for Reproductive Medicine, University Hospital Ghent, De Pintelaan 185, Gent 9000, Belgium
| | - Kelly Tilleman
- Centre for Reproductive Medicine, University Hospital Ghent, De Pintelaan 185, Gent 9000, Belgium
| | - Petra De Sutter
- Centre for Reproductive Medicine, University Hospital Ghent, De Pintelaan 185, Gent 9000, Belgium
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Vandekerckhove F, Vansteelandt S, Gerris J, De Sutter P. Follicle measurements using sonography-based automated volume count accurately predict the yield of mature oocytes in in vitro fertilization/intracytoplasmic sperm injection cycles. Gynecol Obstet Invest 2013; 76:107-12. [PMID: 23868029 DOI: 10.1159/000353432] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Accepted: 05/30/2013] [Indexed: 11/19/2022]
Abstract
AIMS We define criteria to predict the number of mature oocytes using automated three-dimensional (3D) ultrasound follicle measurements. METHODS Fifty in vitro fertilization/intracytoplasmic sperm injection patients underwent automated 3D echographic monitoring by a single researcher following the stimulation procedure. Classic criteria for triggering oocyte maturation as defined in the literature were utilized. 3D parameters, including the follicular volume and follicle diameter calculated from the volume measurement, were related to the oocyte count, mature oocyte count and the number of observed fertilized oocytes. RESULTS We found that when oocyte maturation was induced, 55% of the total follicles with a diameter of at least 10 mm had a volume of at least 1.5 cm³. The number of mature eggs that were retrieved was correlated with the number of follicles observed with a volume of at least 1 cm³ or a calculated follicle diameter of at least 12 mm. CONCLUSION Sonography-based automated volume count measurements of follicle volume and reconstructed follicle diameter can be used to reliably predict the number of mature oocytes.
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