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Wang B, Lin H, Xia R, Lin S, Li Z. Evaluation of birth outcomes, congenital anomalies and neonatal complications of singletons born to infertile women treated with letrozole: A retrospective cohort study. Exp Ther Med 2024; 28:307. [PMID: 38873049 PMCID: PMC11170325 DOI: 10.3892/etm.2024.12596] [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: 12/24/2023] [Accepted: 05/17/2024] [Indexed: 06/15/2024] Open
Abstract
At present, safety of letrozole administration as an ovulation-inducing drug still remains controversial. Investigation of the safety of letrozole use for the induction of ovulation in the Chinese population is scant. The present study aimed to fill this gap. Data concerning mothers using letrozole and birth outcomes of their singleton offspring were collected as the letrozole group (n=194), equivalent data from mothers using non-letrozole drugs and their singleton offspring were included as the non-letrozole group (control, n=154). Birth outcomes, congenital anomalies and neonatal complications were compared and analyzed between the two groups. Univariate analysis, Spearman's rank correlation analysis and the logistic regression model were utilized. For birth outcomes, the percentage of caesarean section deliveries in the letrozole group was lower than the non-letrozole group (43.8 vs. 56.4%, P=0.019). For congenital anomalies, no significant difference was found between the two groups (all P>0.05). The statistical P-value for the correlation between the maternal use of letrozole and neonatal complications was marginal (P=0.051). Results from the logistic regression analysis confirmed that maternal use of letrozole was not a significant contributor for neonatal complications, independent of statistical adjustment [crude odds ratio (OR), 1.436; 95% confidence interval (CI), 0.803-2.569; P=0.223 vs. adjusted OR, 1.406; 95% CI, 0.748-2.643; P=0.290). The results of the present study suggested that maternal use of letrozole for ovulation induction does not associate with poorer birth outcomes or increased risk of congenital anomalies and neonatal complications.
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Affiliation(s)
- Bin Wang
- Reproductive Center, The First Affiliated Hospital of Shantou University Medical College, Shantou University, Shantou, Guangdong 515041, P.R. China
| | - Hong Lin
- Reproductive Center, The First Affiliated Hospital of Shantou University Medical College, Shantou University, Shantou, Guangdong 515041, P.R. China
| | - Rubin Xia
- Reproductive Center, The First Affiliated Hospital of Shantou University Medical College, Shantou University, Shantou, Guangdong 515041, P.R. China
| | - Shuiqin Lin
- Department of Pathology, The First Affiliated Hospital of Shantou University Medical College, Shantou University, Shantou, Guangdong 515041, P.R. China
| | - Zhiling Li
- Reproductive Center, The First Affiliated Hospital of Shantou University Medical College, Shantou University, Shantou, Guangdong 515041, P.R. China
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Peng T, Yang S, Lian W, Liu X, Zheng P, Qin X, Liao B, Zhou P, Wang Y, Liu F, Yang Z, Ye Z, Shan H, Liu X, Yu Y, Li R. Cytoskeletal and inter-cellular junction remodelling in endometrial organoids under oxygen-glucose deprivation: a new potential pathological mechanism for thin endometria. Hum Reprod 2024; 39:1778-1793. [PMID: 38915267 DOI: 10.1093/humrep/deae137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 05/21/2024] [Indexed: 06/26/2024] Open
Abstract
STUDY QUESTION What is the pathological mechanism involved in a thin endometrium, particularly under ischaemic conditions? SUMMARY ANSWER Endometrial dysfunction in patients with thin endometrium primarily results from remodelling in cytoskeletons and cellular junctions of endometrial epithelial cells under ischemic conditions. WHAT IS KNOWN ALREADY A healthy endometrium is essential for successful embryo implantation and subsequent pregnancy; ischemic conditions in a thin endometrium compromise fertility outcomes. STUDY DESIGN, SIZE, DURATION We recruited 10 patients with thin endometrium and 15 patients with healthy endometrium. Doppler ultrasound and immunohistochemical results confirmed the presence of insufficient endometrial blood perfusion in patients with thin endometrium. Organoids were constructed using healthy endometrial tissue and cultured under oxygen-glucose deprivation (OGD) conditions for 24 h. The morphological, transcriptomic, protein expression, and signaling pathway changes in the OGD organoids were observed. These findings were validated in both thin endometrial tissue and healthy endometrial tissue samples. PARTICIPANTS/MATERIALS, SETTING, METHODS Endometrial thickness and blood flow were measured during the late follicular phase using transvaginal Doppler ultrasound. Endometrial tissue was obtained via hysteroscopy. Fresh endometrial tissues were used for the generation and culture of human endometrial organoids. Organoids were cultured in an appropriate medium and subjected to OGD to simulate ischemic conditions. Apoptosis and cell death were assessed using Annexin-V/propidium iodide staining. Immunofluorescence analysis, RNA sequencing, western blotting, simple westerns, immunohistochemistry, and electron microscopy were conducted to evaluate cellular and molecular changes. MAIN RESULTS AND THE ROLE OF CHANCE Patients with thin endometrium showed significantly reduced endometrial thickness and altered blood flow patterns compared to those with healthy endometrium. Immunohistochemical staining revealed fewer CD34-positive blood vessels and glands in the thin endometrium group. Organoids cultured under OGD conditions exhibited significant morphological changes, increased apoptosis, and cell death. RNA-seq identified differentially expressed genes related to cytoskeletal remodeling and stress responses. OGD induced a strong cytoskeletal reorganization, mediated by the RhoA/ROCK signaling pathway. Additionally, electron microscopy indicated compromised epithelial integrity and abnormal cell junctions in thin endometrial tissues. Upregulation of hypoxia markers (HIF-1α and HIF-2α) and activation of the RhoA/ROCK pathway were also observed in thin endometrial tissues, suggesting ischemia and hypoxia as underlying mechanisms. LARGE SCALE DATA none. LIMITATIONS AND REASONS FOR CAUTION The study was conducted in an in vitro model, which may not fully replicate the complexity of in vivo conditions. WIDER IMPLICATIONS OF THE FINDINGS This research provides a new three-dimensional in vitro model of thin endometrium, as well as novel insights into the pathophysiological mechanisms of endometrial ischaemia in thin endometrium, offering potential avenues for identifying therapeutic targets for treating fertility issues related to thin endometrium. STUDY FUNDING/COMPETING INTEREST(S) This study was supported by the National Natural Science Foundation of China (81925013); National Key Research and Development Project of China (2022YFC2702500, 2021YFC2700303, 2021YFC2700601); the Capital Health Research and Development Project (SF2022-1-4092); the National Natural Science Foundation of China (82288102, 81925013, 82225019, 82192873); Special Project on Capital Clinical Diagnosis and Treatment Technology Research and Transformation Application (Z211100002921054); the Frontiers Medical Center, Tianfu Jincheng Laboratory Foundation(TFJC2023010001). The authors declare that no competing interests exist.
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Affiliation(s)
- TianLiu Peng
- Department of Obstetrics and Gynecology, State Key Laboratory of Female Fertility Promotion, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- Ministry of Education, Key Laboratory of Assisted Reproduction (Peking University), Beijing, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, China
- National Clinical Key Specialty Construction Program, Beijing, China
| | - Shuo Yang
- Department of Obstetrics and Gynecology, State Key Laboratory of Female Fertility Promotion, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- Ministry of Education, Key Laboratory of Assisted Reproduction (Peking University), Beijing, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, China
- National Clinical Key Specialty Construction Program, Beijing, China
| | - Weisi Lian
- Department of Obstetrics and Gynecology, State Key Laboratory of Female Fertility Promotion, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- Ministry of Education, Key Laboratory of Assisted Reproduction (Peking University), Beijing, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, China
- National Clinical Key Specialty Construction Program, Beijing, China
| | - Xiaojuan Liu
- Department of Obstetrics and Gynecology, State Key Laboratory of Female Fertility Promotion, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- Ministry of Education, Key Laboratory of Assisted Reproduction (Peking University), Beijing, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, China
- National Clinical Key Specialty Construction Program, Beijing, China
- Clinical Stem Cell Research Center, Peking University Third Hospital, Beijing, China
| | - Ping Zheng
- Department of Obstetrics and Gynecology, State Key Laboratory of Female Fertility Promotion, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- Ministry of Education, Key Laboratory of Assisted Reproduction (Peking University), Beijing, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, China
- National Clinical Key Specialty Construction Program, Beijing, China
- Clinical Stem Cell Research Center, Peking University Third Hospital, Beijing, China
| | - Xunsi Qin
- Department of Obstetrics and Gynecology, State Key Laboratory of Female Fertility Promotion, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- Ministry of Education, Key Laboratory of Assisted Reproduction (Peking University), Beijing, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, China
- National Clinical Key Specialty Construction Program, Beijing, China
| | - Baoying Liao
- Department of Obstetrics and Gynecology, State Key Laboratory of Female Fertility Promotion, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- Ministry of Education, Key Laboratory of Assisted Reproduction (Peking University), Beijing, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, China
- National Clinical Key Specialty Construction Program, Beijing, China
| | - Ping Zhou
- Department of Obstetrics and Gynecology, State Key Laboratory of Female Fertility Promotion, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- Ministry of Education, Key Laboratory of Assisted Reproduction (Peking University), Beijing, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, China
- National Clinical Key Specialty Construction Program, Beijing, China
| | - Yue Wang
- Department of Obstetrics and Gynecology, State Key Laboratory of Female Fertility Promotion, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- Ministry of Education, Key Laboratory of Assisted Reproduction (Peking University), Beijing, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, China
- National Clinical Key Specialty Construction Program, Beijing, China
| | - Fenting Liu
- Department of Obstetrics and Gynecology, State Key Laboratory of Female Fertility Promotion, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- Ministry of Education, Key Laboratory of Assisted Reproduction (Peking University), Beijing, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, China
- National Clinical Key Specialty Construction Program, Beijing, China
| | - Zi Yang
- Department of Obstetrics and Gynecology, State Key Laboratory of Female Fertility Promotion, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- Ministry of Education, Key Laboratory of Assisted Reproduction (Peking University), Beijing, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, China
- National Clinical Key Specialty Construction Program, Beijing, China
| | - Zhenhong Ye
- Department of Obstetrics and Gynecology, State Key Laboratory of Female Fertility Promotion, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- Ministry of Education, Key Laboratory of Assisted Reproduction (Peking University), Beijing, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, China
- National Clinical Key Specialty Construction Program, Beijing, China
| | - Hongying Shan
- Department of Obstetrics and Gynecology, State Key Laboratory of Female Fertility Promotion, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- Ministry of Education, Key Laboratory of Assisted Reproduction (Peking University), Beijing, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, China
- National Clinical Key Specialty Construction Program, Beijing, China
| | - Xiyao Liu
- Department of Obstetrics and Gynecology, State Key Laboratory of Female Fertility Promotion, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- Ministry of Education, Key Laboratory of Assisted Reproduction (Peking University), Beijing, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, China
- National Clinical Key Specialty Construction Program, Beijing, China
| | - Yang Yu
- Department of Obstetrics and Gynecology, State Key Laboratory of Female Fertility Promotion, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- Ministry of Education, Key Laboratory of Assisted Reproduction (Peking University), Beijing, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, China
- National Clinical Key Specialty Construction Program, Beijing, China
- Clinical Stem Cell Research Center, Peking University Third Hospital, Beijing, China
| | - Rong Li
- Department of Obstetrics and Gynecology, State Key Laboratory of Female Fertility Promotion, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- Ministry of Education, Key Laboratory of Assisted Reproduction (Peking University), Beijing, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, China
- National Clinical Key Specialty Construction Program, Beijing, China
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3
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Lu Y, Cherouveim P, Jiang V, Dimitriadis I, James KE, Bormann C, Souter I. The impact of clomiphene citrate on the endometrium in comparison to gonadotropins in intrauterine insemination cycles: is it thinner and does it matter? Front Endocrinol (Lausanne) 2024; 15:1414481. [PMID: 38978628 PMCID: PMC11228293 DOI: 10.3389/fendo.2024.1414481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 06/07/2024] [Indexed: 07/10/2024] Open
Abstract
Objective To determine whether endometrial thickness (EMT) differs between i) clomiphene citrate (CC) and gonadotropin (Gn) utilizing patients as their own controls, and ii) patients who conceived with CC and those who did not. Furthermore, to investigate the association between late-follicular EMT and pregnancy outcomes, in CC and Gn cycles. Methods Retrospective study. Three sets of analyses were conducted separately for the purpose of this study. In analysis 1, we included all cycles from women who initially underwent CC/IUI (CC1, n=1252), followed by Gn/IUI (Gn1, n=1307), to compare EMT differences between CC/IUI and Gn/IUI, utilizing women as their own controls. In analysis 2, we included all CC/IUI cycles (CC2, n=686) from women who eventually conceived with CC during the same study period, to evaluate EMT differences between patients who conceived with CC (CC2) and those who did not (CC1). In analysis 3, pregnancy outcomes among different EMT quartiles were evaluated in CC/IUI and Gn/IUI cycles, separately, to investigate the potential association between EMT and pregnancy outcomes. Results In analysis 1, when CC1 was compared to Gn1 cycles, EMT was noted to be significantly thinner [Median (IQR): 6.8 (5.5-8.0) vs. 8.3 (7.0-10.0) mm, p<0.001]. Within-patient, CC1 compared to Gn1 EMT was on average 1.7mm thinner. Generalized linear mixed models, adjusted for confounders, revealed similar results (coefficient: 1.69, 95% CI: 1.52-1.85, CC1 as ref.). In analysis 2, CC1 was compared to CC2 EMT, the former being thinner both before [Median (IQR): 6.8 (5.5-8.0) vs. 7.2 (6.0-8.9) mm, p<0.001] and after adjustment (coefficient: 0.59, 95%CI: 0.34-0.85, CC1 as ref.). In analysis 3, clinical pregnancy rates (CPRs) and ongoing pregnancy rates (OPRs) improved as EMT quartiles increased (Q1 to Q4) among CC cycles (p<0.001, p<0.001, respectively), while no such trend was observed among Gn cycles (p=0.94, p=0.68, respectively). Generalized estimating equations models, adjusted for confounders, suggested that EMT was positively associated with CPR and OPR in CC cycles, but not in Gn cycles. Conclusions Within-patient, CC generally resulted in thinner EMT compared to Gn. Thinner endometrium was associated with decreased OPR in CC cycles, while no such association was detected in Gn cycles.
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Affiliation(s)
- Yao Lu
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Reproductive Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory for Assisted Reproduction and Reproductive Genetics, Shanghai, China
| | - Panagiotis Cherouveim
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Victoria Jiang
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Irene Dimitriadis
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Kaitlyn E James
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Charles Bormann
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Irene Souter
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
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4
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Zhang WY, McCracken M, Dominguez LV, Zhang A, Johal J, Aghajanova L. The impact of estradiol supplementation on endometrial thickness and intrauterine insemination outcomes. Reprod Biol 2024; 24:100886. [PMID: 38636264 PMCID: PMC11208072 DOI: 10.1016/j.repbio.2024.100886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/19/2024] [Accepted: 04/10/2024] [Indexed: 04/20/2024]
Abstract
The impact of estrogen supplementation during the follicular/proliferative phase on the endometrial lining thickness (EMT) prior to intrauterine insemination (IUI) remains largely unstudied. Our study examined changes in EMT and rates of clinical pregnancy, miscarriage, and live birth for all patients who completed an IUI cycle at Stanford Fertility Center from 2017-2023 (n = 2281 cycles). Cycles with estradiol supplementation (n = 309) were compared to reference cycles without supplementation (n = 1972), with the reference cohort further categorized into cycles with a pre-ovulatory EMT of < 7 mm ("thin-lining", n = 536) and ≥ 7 mm ("normal-lining", n = 1436). The estradiol group had a statistically significant greater change in EMT from baseline to ovulation compared to the thin-lining reference groups (2.4 mm vs 1.9 mm, p < =0.0001). Similar rates of clinical pregnancy and live birth were observed. After adjusting for age, BMI, race/ethnicity, infertility diagnosis, and EMT at trigger, the estradiol cohort had a significantly increased odds of miscarriage versus the entire reference cohort (2.46, 95 % confidence interval [1.18, 5.14], p = 0.02). Thus, although estradiol supplementation had a statistically significant increase in EMT compared to IUI cycles with thin pre-ovulatory EMT (<7 mm), this change did not translate into improved IUI outcomes such as increased rates of clinical pregnancy and live birth or decreased rate of miscarriage. Our study suggests that supplemental estradiol does not appear to improve IUI outcomes.
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Affiliation(s)
- Wendy Y Zhang
- Department of Obstetrics and Gynecology Stanford University School of Medicine, Stanford, CA, USA.
| | - Megan McCracken
- Department of Obstetrics and Gynecology Stanford University School of Medicine, Stanford, CA, USA
| | | | - Amy Zhang
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jasmyn Johal
- Department of Obstetrics and Gynecology Stanford University School of Medicine, Stanford, CA, USA; Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY, USA
| | - Lusine Aghajanova
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Sunnyvale, CA, USA
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Li ZY, Cai L, Zhang ZJ, Zou HR, He M, Qin ML, Wang H. Evaluation of endometrial receptivity in women with unexplained infertility by shear wave elastography. Insights Imaging 2024; 15:85. [PMID: 38517577 PMCID: PMC10959862 DOI: 10.1186/s13244-024-01646-3] [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: 09/28/2023] [Accepted: 02/10/2024] [Indexed: 03/24/2024] Open
Abstract
OBJECTIVES The endometrium of most unexplained infertility (UI) patients has been altered histologically. Shear wave elastography (SWE) is utilized to assess the signature of living tissue. This study aimed to explore the value of SWE in evaluating endometrial receptivity (ER) in UI patients. METHODS In total, 59 UI patients (UI group) and 52 normal control women (NC group) who received fertility consultation in our hospital were included between January 2022 and June 2023. We divided them into the late-proliferative phase of UI group (LPUI; n = 59), mid-secretory phase of UI group (MPUI; n = 41), late-proliferative phase of NC group (LPNC; n = 52), and mid-secretory phase of NC group (MPNC; n = 45). Transvaginal ultrasonography and SWE were performed during the LP and MP. Endometrial thickness (EMT), uterine artery pulsatility index (UA-PI), endometrial mean elasticity (E-mean), and mean shear wave velocities (SWV-mean) were measured. RESULTS There were significant differences in E-mean, SWV-mean, EMT, and UA-PI between the UI group and the NC group during both the LP and MP (p MPNC vs MPUI < 0.05, p LPNC vs LPUI < 0.05). E-mean and SWV-mean decreased with increasing EMT but increased with increasing UA-PI (p < 0.05). The most effective parameter for evaluating ER in UI patients is the E-mean (AUC = 0.89). CONCLUSIONS UI patients exhibited thinner endometrium, increased endometrial stiffness, and poor endometrial blood perfusion. E-mean was the most effective parameter to evaluate ER in UI patients. The study preliminarily proved that SWE is a promising non-invasive tool for evaluating the condition of endometrium. CRITICAL RELEVANCE STATEMENT This study aimed to explore the significance of endometrial elasticity measured by SWE in evaluating patients with UI. The findings revealed a correlation between EMT, UA-PI, and E-mean. Endometrial elasticity can serve as an effective indicator for predicting ER. KEY POINTS 1. To explore the significance of endometrial elasticity in assessing patients with UI. 2. The endometrium of UI patient exhibited thinness, stiffness, and poor blood perfusion. 3. Endometrial elasticity serves as a valuable indicator for evaluating endometrial receptivity.
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Affiliation(s)
- Zheng-Ying Li
- Department of Ultrasound, University-Town Hospital of Chongqing Medical University, No. 55 University Middle Road, Shapingba District, Chongqing, 401331, China
| | - Lu Cai
- Department of Ultrasound, University-Town Hospital of Chongqing Medical University, No. 55 University Middle Road, Shapingba District, Chongqing, 401331, China
| | - Zhi-Jun Zhang
- Department of Ultrasound, University-Town Hospital of Chongqing Medical University, No. 55 University Middle Road, Shapingba District, Chongqing, 401331, China
| | - Hai-Rong Zou
- Department of Ultrasound, University-Town Hospital of Chongqing Medical University, No. 55 University Middle Road, Shapingba District, Chongqing, 401331, China
| | - Mei He
- Department of Ultrasound, University-Town Hospital of Chongqing Medical University, No. 55 University Middle Road, Shapingba District, Chongqing, 401331, China
| | - Mei-Lin Qin
- Department of Ultrasound, University-Town Hospital of Chongqing Medical University, No. 55 University Middle Road, Shapingba District, Chongqing, 401331, China
| | - Hui Wang
- Department of Ultrasound, University-Town Hospital of Chongqing Medical University, No. 55 University Middle Road, Shapingba District, Chongqing, 401331, China.
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Wei W, Wang N, Zhu Y, Liao M, Wang B, Du T, Zhang J, Mao X. GM-CSF improves endometrial receptivity in a thin endometrium rat model by upregulating HOXA10. Mol Hum Reprod 2023; 30:gaad042. [PMID: 38011650 DOI: 10.1093/molehr/gaad042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 11/16/2023] [Indexed: 11/29/2023] Open
Abstract
Endometrial receptivity is a prerequisite for the success of assisted reproduction. Patients with a consistently thin endometrium frequently fail to conceive, owing to low endometrial receptivity, and there are currently very few therapeutic options available. Our previous study demonstrated that intrauterine granulocyte-macrophage colony-stimulating factor (GM-CSF) administration resulted in a significant improvement in clinical pregnancy and implantation rates and was an effective means of increasing endometrial thickness on the day of embryo transfer in patients with thin endometrium. In order to explore the underlying process, an animal model with a thin endometrium was constructed, the homeobox A10 gene (HOXA10) was downregulated, and an inhibitor of the mitogen-activated protein kinase/extracellular signal-regulated kinase pathway (MAPK/ERK) was employed. Our findings strongly suggest a marked decrease in GM-CSF levels in the thin endometrial rat model, and the suppression of HOXA10 impeded the therapeutic efficacy of GM-CSF in this model. Moreover, we showed that GM-CSF significantly increases endometrial receptivity in the rat model and upregulates HOXA10 via the MAPK/ERK pathway. Our data provide new molecular insights into the mechanisms underlying formation of a thin endometrium and highlight a novel, potential clinical treatment strategy as well as directions for further research.
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Affiliation(s)
- Wei Wei
- Key Laboratory of Systems Biomedicine (Ministry of Education), Shanghai Center for Systems Biomedicine, Shanghai Jiao Tong University, Shanghai, China
| | - Na Wang
- Key Laboratory of Systems Biomedicine (Ministry of Education), Shanghai Center for Systems Biomedicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yanwen Zhu
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Maokun Liao
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bian Wang
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tong Du
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jie Zhang
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoyan Mao
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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7
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Mathyk B, Schwartz A, DeCherney A, Ata B. A critical appraisal of studies on endometrial thickness and embryo transfer outcome. Reprod Biomed Online 2023; 47:103259. [PMID: 37516058 PMCID: PMC10528454 DOI: 10.1016/j.rbmo.2023.103259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/22/2023] [Accepted: 06/29/2023] [Indexed: 07/31/2023]
Abstract
A receptive endometrium is required for successful embryo implantation. Endometrial thickness, as measured by ultrasonography, is the most commonly used marker of endometrial receptivity in assisted reproductive technology cycles. Several factors simultaneously affect both endometrial thickness and probability of live birth, including age, oestradiol concentration and oocyte number, among others. Most of the studies investigating a relationship between endometrial thickness and embryo transfer outcomes are retrospective and do not adequately address confounding factors, in addition to other limitations. Despite multiple meta-analyses and studies with large numbers of cycles, controversy still exists. The difference between the results from prospective and retrospective studies is also striking. This article presents a critical appraisal of the studies on endometrial thickness and embryo transfer outcomes in order to highlight methodological issues and how they can be overcome in future studies. Currently available evidence does not seem to support a modification of management just because endometrial thickness is below an arbitrary threshold.
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Affiliation(s)
- Begum Mathyk
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Adina Schwartz
- Reproductive Endocrinology and Infertility Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Alan DeCherney
- Reproductive Endocrinology and Infertility Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Baris Ata
- School of Medicine, Koç University, Istanbul, Turkey.; ART Fertility Clinics, Dubai, United Arab Emirates..
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Craig LB, Jarshaw CL, Hansen KR, Peck JD. Association between obesity and fecundity in patients undergoing intrauterine insemination. F S Rep 2023; 4:270-278. [PMID: 37719104 PMCID: PMC10504554 DOI: 10.1016/j.xfre.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 02/25/2023] [Accepted: 05/15/2023] [Indexed: 09/19/2023] Open
Abstract
Objective To determine if an association exists between body mass index (BMI) and fecundity after intrauterine insemination (IUI). Design Retrospective cohort study. Setting Academic-based fertility clinic. Patients Patients undergoing IUI July 2007 to May 2012. Interventions None. Main Outcome Measures Primary outcome: live-birth rate (LBR) per IUI cycle; secondary outcomes: positive pregnancy test and clinical pregnancy rates (CPRs). Results A total of 1959 cycles were performed on 661 women (mean age, 31.9 ± 4.9 years). When examined by obesity class, LBR and CPR were similar for women with class I, II, and III obesity when compared with women with normal BMI. However, class III obese women (adjusted risk ratio [aRR], 1.70; 95% confidence interval [CI], 1.12-2.59) had increased pregnancy rates compared with normal BMI, but no differences in pregnancy rates were observed for women with class I or II obesity. In addition, pregnancy rates (aRR, 1.50; 95% CI, 1.12-2.02) and CPR (aRR, 1.51; 95% CI, 1.07-2.14) were higher in overweight women relative to normal BMI. Notably, among patients with ovulatory dysfunction, CPRs after IUI were reduced by 43% in obese women (aRR, 0.57; 95% CI, 0.37-1.07), whereas women without ovulatory dysfunction were twice as likely to achieve a clinical pregnancy when they were obese (aRR, 1.96; 95% CI, 1.19-3.24). The CIs for the obesity risk ratios in each stratum of ovulatory function exhibited no overlap, suggesting evidence of potential effect modification by ovulatory function. Conclusions LBRs after IUI were similar across BMI subgroups. This is in contrast to research of in vitro fertilization treatments showing lower LBR with increasing BMI. However, obesity may adversely affect IUI CPR in those with ovulatory dysfunction in particular. The reason for this discrepancy is unclear and warrants further study.
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Affiliation(s)
- LaTasha B. Craig
- Section of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Christen L. Jarshaw
- Section of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Karl R. Hansen
- Section of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Jennifer D. Peck
- Department of Biostatistics and Epidemiology, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Fang Z, Huang J, Mao J, Yu L, Wang X. Effect of endometrial thickness on obstetric and neonatal outcomes in assisted reproduction: a systematic review and meta-analysis. Reprod Biol Endocrinol 2023; 21:55. [PMID: 37312205 DOI: 10.1186/s12958-023-01105-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/23/2023] [Indexed: 06/15/2023] Open
Abstract
PURPOSE This systematic review and meta-analysis aimed to explore the relationship of endometrial thickness (EMT) with obstetric and neonatal outcomes in assisted reproductive cycles. METHODS PubMed, EMBASE, Cochrane Library and Web of Science were searched for eligible studies through April 2023. Obstetric outcomes include placenta previa, placental abruption, hypertensive disorders of pregnancy (HDP), gestational diabetes mellitus (GDM) and cesarean section (CS). Neonatal outcomes include birthweight, low birth weight (LBW), gestational age (GA), preterm birth (PTB), small for gestational age (SGA) and large for gestational age (LGA). The effect size was estimated as odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) using a random-effects model. Inter-study heterogeneity was assessed by the chi-square homogeneity test. One-study removal method was used to determine the sensitivity of the meta-analysis. RESULTS Nineteen studies involving 76,404 cycles were included. The pooled results revealed significant differences between the thin endometrium group and the normal group in placental abruption (OR = 2.45, 95% CI: 1.11-5.38, P = 0.03; I2 = 0%), HDP (OR = 1.72, 95% CI: 1.44-2.05, P < 0.0001; I2 = 0%), CS (OR = 1.33, 95% CI: 1.06-1.67, P = 0.01; I2 = 77%), GA (MD = -1.27 day, 95% CI: -2.41- -1.02, P = 0.03; I2 = 73%), PTB (OR = 1.56, 95% CI: 1.34-1.81, P < 0.0001; I2 = 33%), birthweight (MD = -78.88 g, 95% CI: -115.79- -41.98, P < 0.0001; I2 = 48%), LBW (OR = 1.84, 95% CI: 1.52-2.22, P < 0.00001; I2 = 3%) and SGA (OR = 1.41, 95% CI: 1.17-1.70, P = 0.0003; I2 = 15%). No statistical differences were found in placenta previa, GDM, and LGA. CONCLUSION Thin endometrium was associated with lower birthweight or GA and higher risks of placental abruption, HDP, CS, PTB, LBW and SGA. Therefore, these pregnancies need special attention and close follow-up by obstetricians. Due to the limited number of included studies, further studies are needed to confirm the results.
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Affiliation(s)
- Zheng Fang
- Department of Gynecology and Obstetrics, Reproductive Medical Center, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Jialyu Huang
- Reproductive Medical Center, Jiangxi Maternal and Child Health Hospital, Nanchang Medical College, Nanchang, China
| | - Jiaqin Mao
- Department of Gynecology and Obstetrics, Reproductive Medical Center, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Lamei Yu
- Department of Obstetrics, Jiangxi Maternal and Child Health Hospital, Nanchang Medical College, Nanchang, China
| | - Xiaohong Wang
- Department of Gynecology and Obstetrics, Reproductive Medical Center, Tangdu Hospital, Air Force Medical University, Xi'an, China.
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Luo Q, Qin J, Wang H, Hu Y, Yang L, Mao T, Yi L, Liu W, Zeng Q, Qiu Y. Factors associated with spontaneous miscarriage risk in IUI treatment: A retrospectively cohort of 31,933 cycles. Eur J Obstet Gynecol Reprod Biol 2023; 286:61-68. [PMID: 37209524 DOI: 10.1016/j.ejogrb.2023.05.005] [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: 10/09/2022] [Revised: 03/22/2023] [Accepted: 05/06/2023] [Indexed: 05/22/2023]
Abstract
To determine the factors associated with intrauterine insemination (IUI) miscarriages and reduce the IUI miscarriage rate, a retrospective study was performed by reviewing 31,933 IUI cycles from 2006 to 2018. The overall there were 14.50% clinical pregnancies, and 16.74% miscarriages. Logistic regression revealed the following three predictive variables: females aged ≥ 35 years (odds ratio [OR] = 2.131; p < 0.001), spontaneous miscarriage history (OR = 1.513; p = 0.005), and ovarian stimulation schemes such as clomiphene citrate (CC) (OR = 1.459; p = 0.003). The natural cycle led to a lower miscarriage rate for patients without spontaneous miscarriage history both for those over 35 years old (OR = 0.402; p = 0.034) and for those under 35 years old (OR = 0.806; p = 0.017). Gonadotropin (Gn) showed the lowest miscarriage rate for patients without abortion history, though no significant differences were found. Patients under 35 with a history of miscarriage were protected from miscarriage by using CC and Gn together (OR = 0.516; p = 0.032). No significant differences were found between various ovarian protocols when patients with abortion history were aged ≥ 35 years (p = 0.606). CC + Gn showed the lowest miscarriage rate. In conclusion, the natural cycle could be suggested for infertility couples to minimize abortion risk. When ovarian induction is required, CC + Gn had the lowest miscarriage rate for women with a history of spontaneous miscarriage while Gn is more successful for individuals without such a history.
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Affiliation(s)
- Qiongxiu Luo
- Jiangxi province Ji'an Women and Child Health care Hospital (Children's Hospital), Ji'an, PR China
| | - Jiaying Qin
- Translational Center for Stem Cell Research, Tongji Hospital, Department of Regenerative Medicine, Tongji University School of Medicine, Shanghai, PR China
| | - Huan Wang
- Jiangxi province Ji'an Women and Child Health care Hospital (Children's Hospital), Ji'an, PR China
| | - Yinyan Hu
- Jiangxi province Ji'an Women and Child Health care Hospital (Children's Hospital), Ji'an, PR China
| | - Lan Yang
- Jiangxi province Ji'an Women and Child Health care Hospital (Children's Hospital), Ji'an, PR China
| | - Taifeng Mao
- Jiangxi province Ji'an Women and Child Health care Hospital (Children's Hospital), Ji'an, PR China
| | - Ling Yi
- Jiangxi province Ji'an Women and Child Health care Hospital (Children's Hospital), Ji'an, PR China
| | - Wenyan Liu
- Jiangxi province Ji'an Women and Child Health care Hospital (Children's Hospital), Ji'an, PR China
| | - Qiao Zeng
- Jiangxi province Ji'an Women and Child Health care Hospital (Children's Hospital), Ji'an, PR China.
| | - Yu Qiu
- Jiangxi province Ji'an Women and Child Health care Hospital (Children's Hospital), Ji'an, PR China.
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11
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Pandey D, Bajaj B, Kapoor G, Bharti R. Intrauterine instillation of autologous platelet-rich plasma in infertile females with thin endometrium undergoing intrauterine insemination: an open-label randomized controlled trial. AJOG GLOBAL REPORTS 2023; 3:100172. [PMID: 36960130 PMCID: PMC10027558 DOI: 10.1016/j.xagr.2023.100172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND Thin endometrium in infertile female patients has always been a clinical challenge for the treating reproductive physicians. OBJECTIVE This study aimed to evaluate the effect of intrauterine instillation of autologous platelet-rich plasma on endometrial thickness and vascularity in infertile female patients with thin endometrium undergoing ovarian stimulation with intrauterine insemination. STUDY DESIGN This prospective randomized control study included 120 women undergoing ovarian stimulation with intrauterine insemination, aged between 21 and 37 years, with persistent thin endometrium (<7 mm) on ≥1 cycle in previous ovarian stimulation cycles, even after conventional treatment with estradiol valerate. The women were randomly assigned to study group A and control group B. Baseline endometrial thickness and endometrial vascularity were noted. Intrauterine instillation of autologous platelet-rich plasma was done on the day of trigger in group A, whereas estradiol valerate was given in group B. Another evaluation of endometrial parameters was done on the day of intrauterine insemination. The cycle was repeated for 3 cycles or until the pregnancy was achieved, whichever occurred earlier. Parameters were noted for both groups. Primary outcomes were the change in endometrial thickness and endometrial vascularity. Secondary outcomes were positive pregnancy rate and clinical pregnancy rate. RESULTS In group A, mean pre-platelet-rich plasma endometrial thickness was 4.66±0.79 mm, which significantly increased to 7.47±0.85 mm after platelet-rich plasma instillation (P<.05) after 3 cycles. This increase was significantly greater than that observed in group B. There was significant increase in endometrial vascularity in group A compared with group B (P<.05). The positive pregnancy rate and clinical pregnancy rate in group A were 23.73% and 18.64%, respectively, and significantly higher than those in group B. CONCLUSION Autologous platelet-rich plasma is a promising, easily procurable, and novel option for management of infertile females with thin endometrium not responding to conventional treatment. Using it in intrauterine insemination cycles can reduce costs and psychological burden of this subgroup of women by reducing the need for resorting to advanced options such as in vitro fertilization and surrogacy.
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Hernandez-Nieto C, Lee J, Alkon-Meadows T, Soto-Cossio L, Sandler B, Mukherjee T, Copperman A. Recent clomiphene citrate exposure does not impact subsequent clinical outcomes in single euploid frozen embryo transfer cycles. Hum Reprod 2023:7131351. [PMID: 37075318 DOI: 10.1093/humrep/dead072] [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: 10/18/2022] [Revised: 03/27/2023] [Indexed: 04/21/2023] Open
Abstract
STUDY QUESTION Do infertile couples who recently utilized clomiphene citrate (CC) for ovulation induction or ovarian stimulation (<90 days previously) followed by a single euploid embryo transfer (SEET) have lower implantation potential compared with patients who were not exposed to CC within 90 days before embryo transfer (ET)? SUMMARY ANSWER There does not appear to be an association between recent CC exposure and lower implantation potential in patients who undergo a frozen embryo transfer (FET) of euploid embryos. WHAT IS KNOWN ALREADY Clomiphene has been found to be associated with lower pregnancy rates when compared against other ovarian stimulation medications. The majority of published research about the effects of CC on implantation potential suggest an anti-estrogenic effect on the endometrium. Quality evidence and information about utilization of CC and its effect on implantation potential after euploid ETs is lacking in the literature. STUDY DESIGN, SIZE, DURATION A retrospective cohort study with propensity score matching was carried out. We included all patients that underwent an autologous SEET from September 2016 to September 2022 at a single academic-private ART center. PARTICIPANTS/MATERIALS, SETTING, METHODS The study group included patients that had utilized CC during either ovulation induction cycles and/or controlled ovarian stimulation at least 90 days before FET. A propensity score-matched control group of patients that were unexposed to CC within 90 days prior to SEET was used for comparisons. The primary outcome was positive pregnancy test (defined as a positive serum β-hCG measured 9 days after ET), with other outcomes including clinical pregnancy, ongoing pregnancy, biochemical pregnancy loss, and clinical pregnancy loss rates per SEET. Multivariate regression analyses fitted with generalized estimating equations were utilized to analyze if there was an association between CC utilization and IVF outcomes. Furthermore, the study evaluated the cumulative effect of CC and endometrial receptivity in vivo and subsequent IVF outcomes. MAIN RESULTS AND THE ROLE OF CHANCE A total of 593 patients with utilization of CC in <90 days before ET were compared with 1779 matched controls. Positive pregnancy test rates were comparable among the control group and the CC exposed groups, respectively (74.3% versus 75.7%, P = 0.79), as were clinical pregnancy (64.0% versus 65.0%, P = 0.60), ongoing pregnancy (51.8% versus 53.2%, P = 0.74), biochemical pregnancy loss (15.7% versus 14.03%, P = 0.45), and clinical pregnancy loss rates were also comparable among cohorts (17.1% versus 18.1%, P = 0.71). No association was found between utilization of clomiphene and lower implantation rates (adjusted odds ratio 0.95, 95% CI 0.76-1.18). Also, no differences were observed in sub-analyses based on multiple CC utilization periods. Finally, no association was found between the number of consecutive cumulative clomiphene cycles and sub-optimal IVF outcomes. LIMITATIONS, REASONS FOR CAUTION The study has inherent bias that originated from its retrospective design. Serum levels of CC were not measured and sample size for the sub-analyses was small. WIDER IMPLICATIONS OF THE FINDINGS There does not appear to be an association between recent CC exposure and lower implantation potential in patients who undergo a FET of euploid embryos. This finding remains consistent, even in patients who undergo multiple, consecutive clomiphene cycles prior to ET. There were no long-term effects of CC on endometrial development and clinical characteristics examined in this study. Patients that utilized CC medication prior to a SEET cycle for either ovarian stimulation or ovulation induction, can be assured that there is no evidence of a residual effect of recent CC administration that could jeopardize their pregnancy probability. STUDY FUNDING/COMPETING INTEREST(S) No funding was received for the realization of this study. A.C. is advisor and/or board member of Sema4 (stakeholder in data) and Progyny. The other authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
| | - Joseph Lee
- Reproductive Medicine Associates of New York, New York, NY, USA
| | | | - Luz Soto-Cossio
- Reproductive Medicine Associates of New York, New York, NY, USA
| | - Benjamin Sandler
- Reproductive Medicine Associates of New York, New York, NY, USA
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tanmoy Mukherjee
- Reproductive Medicine Associates of New York, New York, NY, USA
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alan Copperman
- Reproductive Medicine Associates of New York, New York, NY, USA
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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13
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Koshy AK. Improving Fertility Treatment Documentation - A Survey. J Hum Reprod Sci 2023; 16:121-124. [PMID: 37547089 PMCID: PMC10404015 DOI: 10.4103/jhrs.jhrs_34_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/31/2023] [Accepted: 05/31/2023] [Indexed: 08/08/2023] Open
Abstract
Background Many couples do not have adequate documentation following fertility treatments. Aims To conduct a survey to understand the information needs of assisted reproductive technology physicians when assessing the reasons affecting treatment outcomes after intrauterine insemination (IUI) and in vitro fertilisation (IVF). Settings and Design Online survey. Materials and Methods Anonymous online survey of 14 parameters related to IUI treatment and 21 parameters related to IVF treatment, followed by recommendation of selected parameters for routine documentation. Statistical Analysis Used Frequency distribution calculation of responses. Results For IUI, total motile sperm count and post-wash sperm count and motility and for IVF, the quality and number of gametes, embryo number and morphology were the most important parameters. Conclusion The study creates recommendations for the minimum information desirable in the fertility treatment documentation given to the couple undergoing treatment.
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Affiliation(s)
- Aby Kottal Koshy
- Department of Reproductive Medicine, Sunrise Institute of Medical Sciences, Kakkanad, Kerala, India
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14
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Vagios S, Sacha CR, James KE, Hammer KC, Fitz VW, Dimitriadis I, Bormann CL, Souter I. The impact of anti-Müllerian hormone on endometrial thickness in gonadotropin stimulation/intrauterine insemination cycles: is there an effect on pregnancy outcomes? J Assist Reprod Genet 2023; 40:845-850. [PMID: 36745295 PMCID: PMC10224886 DOI: 10.1007/s10815-023-02736-9] [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: 11/08/2022] [Accepted: 01/27/2023] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To study the association, if any, between anti-Müllerian hormone (AMH) and pre-ovulatory endometrial thickness (ET) in gonadotropin/intrauterine insemination (IUI) cycles. METHODS This retrospective cohort study included a total of 964 patients undergoing 1926 gonadotropin/IUI cycles at an academic fertility center. Primary outcome measure was the association between serum AMH and measured ET on the day of and the day before human chorionic gonadotropin hormone (hCG) ovulation trigger. The effect of a model combining AMH and ET on early pregnancy outcomes was a secondary measure. RESULTS In 52.8% of cycles, ET was last assessed and recorded on the day of hCG administration, while in the remaining 47.2% on the day prior to trigger. In unadjusted regression models, AMH was weakly correlated with ET on hCG trigger day [bAMH (95%CI) = 0.032 (- 0.008, 0.070), p = 0.015]. When adjusting for potential confounders, the positive correlation became significant [0.051 (0.006, 0.102), p = 0.047]. Similar findings were observed when assessing the correlation between AMH and ET on the day prior to hCG trigger. ET was non-significantly associated with the odds of clinical pregnancy, when adjusting for potential confounders, except for when restricting the analysis to couples with idiopathic infertility [OR (95%CI), p-value: 0.787 (0.623, 0.993), 0.044]. CONCLUSION Our findings support an effect of serum AMH on endometrial development in gonadotropin induced cycles, even when adjusting for the diagnosis of PCOS. ET was not associated with the odds of achieving a clinical pregnancy, except for couples with idiopathic infertility.
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Affiliation(s)
- Stylianos Vagios
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Reproductive Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
- Department of Obstetrics and Gynecology, Tufts Medical Center, 800 Washington Street, Boston, MA, 02111, USA.
| | - Caitlin R Sacha
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Reproductive Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Kaitlyn E James
- Deborah Kelly Center for Outcomes Research, Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Karissa C Hammer
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Reproductive Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Victoria W Fitz
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Reproductive Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Irene Dimitriadis
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Reproductive Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Charles L Bormann
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Reproductive Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Irene Souter
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Reproductive Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
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15
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Siblini H, Al-Hendy A, Segars J, González F, Taylor HS, Singh B, Flaminia A, Flores VA, Christman GM, Huang H, Johnson JJ, Zhang H. Assessing the Hepatic Safety of Epigallocatechin Gallate (EGCG) in Reproductive-Aged Women. Nutrients 2023; 15:320. [PMID: 36678191 PMCID: PMC9861948 DOI: 10.3390/nu15020320] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/01/2023] [Accepted: 01/02/2023] [Indexed: 01/11/2023] Open
Abstract
A similar abstract of the interim analysis was previously published in Fertility and Sterility. EPIGALLOCATECHIN GALLATE (EGCG) FOR TREATMENT OF UNEXPLAINED INFERTILITY ASSOCIATED WITH UTERINE FIBROIDS (PRE-FRIEND TRIAL): EARLY SAFETY ASSESSMENT. Uterine fibroids are the most common cause of unexplained infertility in reproductive-aged women. Epigallocatechin gallate (EGCG), a green tea catechin, has demonstrated its ability to shrink uterine fibroids in prior preclinical and clinical studies. Hence, we developed an NICHD Confirm-funded trial to evaluate the use of EGCG for treating women with fibroids and unexplained infertility (FRIEND trial). Prior to embarking on that trial, we here conducted the pre-FRIEND study (NCT04177693) to evaluate the safety of EGCG in premenopausal women. Specifically, our aim was to assess any adverse effects of EGCG alone or in combination with an ovarian stimulator on serum liver function tests (LFTs) and folate level. In this randomized, open-label prospective cohort, participants were recruited from the FRIEND-collaborative clinical sites: Johns Hopkins University, University of Chicago, University of Illinois at Chicago, and Yale University. Thirty-nine women, ages ≥18 to ≤40 years, with/without uterine fibroids, were enrolled and randomized to one of three treatment arms: 800 mg of EGCG daily alone, 800 mg of EGCG daily with clomiphene citrate 100 mg for 5 days, or 800 mg of EGCG daily with Letrozole 5 mg for 5 days. No subject demonstrated signs of drug induced liver injury and no subject showed serum folate level outside the normal range. Hence, our data suggests that a daily dose of 800 mg of EGCG alone or in combination with clomiphene citrate or letrozole (for 5 days) is well-tolerated and is not associated with liver toxicity or folate deficiency in reproductive-aged women.
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Affiliation(s)
- Hiba Siblini
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL 60637, USA
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL 60637, USA
| | - James Segars
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Frank González
- Department of Obstetrics and Gynecology, University of Illinois Chicago, Chicago, IL 60607, USA
| | - Hugh S. Taylor
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University, New Haven, CT 06520, USA
| | - Bhuchitra Singh
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Ainna Flaminia
- Department of Obstetrics and Gynecology, University of Illinois Chicago, Chicago, IL 60607, USA
| | - Valerie A. Flores
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University, New Haven, CT 06520, USA
| | - Gregory M. Christman
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL 32610, USA
| | - Hao Huang
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT 06510, USA
| | - Jeremy J. Johnson
- Department of Pharmacy Practice, University of Illinois Chicago, Chicago, IL 60607, USA
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT 06510, USA
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Farshchian N, Fakheri T, Bahrami Kamangar P, Lorestani H, Azadbakht J. Pregnancy rate in intrauterine insemination, is uterine biophysical profile of predictive value? A prospective study. J Ultrasound 2022; 25:949-955. [PMID: 35262850 PMCID: PMC9705682 DOI: 10.1007/s40477-022-00670-7] [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: 12/31/2021] [Accepted: 02/11/2022] [Indexed: 11/28/2022] Open
Abstract
PURPOSE This study aimed at evaluating the value of uterine biophysical profile (UBP) scoring to predict the pregnancy rate after IUI. METHODS This prospective study was carried out on 85 women who were referred to our tertiary teaching center with infertility of male factor or unknown etiology infertility in 2018. To measure the uterine biophysical criteria, transvaginal ultrasonography (TVS) was performed on the day of beta-human chorionic gonadotropin (B-hCG) injection, and the results were evaluated based on positive B-hCG. RESULTS 85 patients were included with a mean age of 30 years; of those 12 (14.1%) were able to conceive. UBP (p = 0.151) and it's parameters (including endometrial thickness, number of endometrial layers, myometrial echogenicity, uterine artery pulsatility index, myometrial blood flow internal to arcuate vessels, endometrial blood flow in the third zone of endometrium, myometrial contraction frequency, and ovarian follicle (OF) size [p = 0.05, 0.89, 0.59, 0.79, 1, 1, 0.59, and 0.77, respectively]) were not significantly associated with pregnancy rate. 91.7% of the cases with positive pregnancy test results, had a UBP score of > 13; however, UBP score was not meaningfully associated with IUI treatment success rate (p = 0.15). CONCLUSIONS UBP scoring system seems to need more data for external validation, or it might require modifications before implementation, as it may cause false reassurance.
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Affiliation(s)
- Nazanin Farshchian
- Department of Radiology, Clinical Research Development Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Taravat Fakheri
- Department of Obstetrics and Gynecology, Clinical Research Development Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Parisa Bahrami Kamangar
- Department of Radiology, Clinical Research Development Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Hassan Lorestani
- Department of Radiology, Clinical Research Development Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Javid Azadbakht
- Department of Radiology, Faculty of Medicine, Shahid Beheshti Hospital, Kashan University of Medical Sciences, Qotb Ravandi Blvd., 8715981151, Kashan, Iran.
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Song H, Guan H, Tang H, Tang L. Effect of ovulation before or after intrauterine insemination on pregnancy outcome in patients with unexplained infertility or polycystic ovarian syndrome. Gynecol Endocrinol 2022; 38:960-964. [PMID: 36184827 DOI: 10.1080/09513590.2022.2125952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE To investigate the relationship between ovulation and pregnancy outcomes in patients undergoing intrauterine insemination (IUI). METHODS The clinical data from 784 patients, diagnosed with polycystic ovarian syndrome (PCOS) or unexplained infertility, underwent 1624 IUI cycles were analyzed retrospectively. Ovulation was observed by transvaginal ultrasonography on the day of IUI. The clinical pregnancy rate (CPR), abortion rate (AR), and live birth rate (LBR) were analyzed. RESULTS The study included 1031 pre-ovulation IUI cycles (63.49%) and 593 post-ovulation IUI cycles (36.51%). The CPR was 13.05%, the AR was 15.57%, and the LBR was 11.02%. Ovulation before or after IUI affected the CPR (11.06% VS 16.53%, p = .002) and LBR (9.41% VS 13.83%, p = .006) per cycle, but did not affect the AR (14.91% VS 16.33%, p = .149). The sex ratio of children was not related to ovulation (p = .948). After adjusting for baseline characteristics and logistic regression, the CPR (OR = 1.931, 95% CI 1.062-1.931, p = .019) and LBR (OR = 1.389, 95% CI 1.007-1.916, p = .045) of post-ovulation insemination were higher than those of pre-ovulation insemination significantly. CONCLUSION Pregnancy outcomes were affected by ovulation on the day of IUI in patients with unexplained infertility or PCOS. Post-ovulation insemination may improve the CPR of IUI.
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Affiliation(s)
- Hang Song
- Clinical Center of Reproductive Medicine, Lianyungang Maternal and Child Health Hospital, Jiangsu, Lianyungang, China
| | - Huijuan Guan
- Clinical Center of Reproductive Medicine, Lianyungang Maternal and Child Health Hospital, Jiangsu, Lianyungang, China
| | - Huaiyun Tang
- Clinical Center of Reproductive Medicine, Lianyungang Maternal and Child Health Hospital, Jiangsu, Lianyungang, China
| | - Lisha Tang
- Clinical Center of Reproductive Medicine, Lianyungang Maternal and Child Health Hospital, Jiangsu, Lianyungang, China
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ÖZGÖKÇE Ç, OÇAL A, EGE S. Effect of oral estrogen supplement on gonadotropin-induced intrauterine insemination: A retrospective cohort study. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2022. [DOI: 10.32322/jhsm.1128579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aim: The effect of estrogen on gonadotropin-induced intrauterine insemination (GI-IUI) is not well studied. Furthermore, risk factors for clinical pregnancy rates are not clearly defined. This study aimed to evaluate the effects of oral estrogen supplementation and clinical pregnancy rates on GI-IUI.
Material and Method: Patients treated with primary and secondary infertility were retrospectively analyzed between September 2016 and September 2019. IUI session was performed after ovarian stimulation with human chorionic gonadotropin. Patients were supplemented with a vaginal gel containing progesterone and oral estrogen (Group A) or only the vaginal gel (Group B). The differences between the groups in pregnancy rate and endometrial thickness and the risk factors associated with clinical pregnancy were determined as primary and secondary outcomes, respectively.
Results: A total of 112 couples were evaluated, where the mean age for females was 31.3±6.1 years. Group A and Group B had 33 (29.5%) and 79 patients (70.5%), respectively. Duration of infertility, number of follicles, and endometrial thickness were significantly different between the two groups. The rate of pregnancy was significantly higher in Group A (51.5%) than in Group B (19%) (p=0.001). There were significant differences between positive and negative pregnancy cases in terms of age, type and duration of infertility, estradiol level, motile sperm number and morphology, number of follicles, and endometrial thickness. The follicle count and estradiol levels were significant risk factors for clinical pregnancy.
Conclusion: Estrogen has a positive effect on pregnancy rates in GI-IUI. The follicle number and estradiol level can be used as a risk factor for IUI.
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Affiliation(s)
- Çağdaş ÖZGÖKÇE
- İstanbul Zeynep Kamil Kadın ve Çocuk Hastalıkları Hastanesi
| | - Aydın OÇAL
- İstanbul Zeynep Kamil Kadın ve Çocuk Hastalıkları Hastanesi
| | - Serhat EGE
- Diyarbakır Gazi Yaşargil Eğitim ve Araştırma Hastanesi
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Vyrides AA, El Mahdi E, Giannakou K. Ovulation induction techniques in women with polycystic ovary syndrome. Front Med (Lausanne) 2022; 9:982230. [PMID: 36035398 PMCID: PMC9411864 DOI: 10.3389/fmed.2022.982230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
Anovulation is very common and has several different clinical manifestations, including amenorrhea, oligomenorrhea and abnormal uterine bleeding. Various mechanisms can cause anovulation. The clinical consequences and commonest chronic anovulatory disorder, polycystic ovary syndrome (PCOS), has a prevalence that ranges between 6 to 10% of the global population. While multiple causes can eventually result in PCOS, various methods have been described in the literature for its management, often without ascertaining the underlying cause. Ovulation Induction (OI) is a group of techniques that is used in women with PCOS who are looking to conceive and are unbale to do so with natural means. This narrative review presents a summary of the current evidence and available techniques for OI in women with PCOS, highlighting their performance and applicability.
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Affiliation(s)
- Andreas A. Vyrides
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Essam El Mahdi
- Department of Obstetrics and Gynecology, Newham University Hospital NHS Trust, London, United Kingdom
| | - Konstantinos Giannakou
- Department of Health Sciences, School of Sciences, European University Cyprus, Nicosia, Cyprus
- *Correspondence: Konstantinos Giannakou
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Jacobs EA, Van Voorhis B, Kawwass JF, Kondapalli LA, Liu K, Dokras A. Endometrial thickness: How thin is too thin? Fertil Steril 2022; 118:249-259. [PMID: 35878944 DOI: 10.1016/j.fertnstert.2022.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 05/19/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Emily A Jacobs
- Division of Reproductive Endocrinology and Infertility, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Brad Van Voorhis
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Jennifer F Kawwass
- Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Emory Reproductive Center, Atlanta, Georgia
| | | | - Kimberly Liu
- Mount Sinai Fertility, University of Toronto, Toronto, Ontario, Canada
| | - Anuja Dokras
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania.
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Zhang S, Tang HH, Zhou ML. Impact of prolonged one or more natural menstrual cycles on the outcomes of ovulation induction intrauterine artificial insemination pregnancy: a single-centre, retrospective study in China. BMJ Open 2022; 12:e061043. [PMID: 35725260 PMCID: PMC9214352 DOI: 10.1136/bmjopen-2022-061043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES We determined if the time interval between two ovulation induction intrauterine artificial insemination (IUI) treatment cycles should be extended by one or more natural menstrual cycles in patients undergoing successive cycles of ovulation stimulation, and whether this affects clinical pregnancy rate (CPR). DESIGN This study was conducted on infertility patients treated under the ovulation induction programme IUI in a large reproductive centre in China. Study participants were assigned into continuous and discontinuous groups. Differences in baseline clinical pregnancy and abortion rates were compared between the groups. A multivariate logistic model was used to evaluate the effects of time interval on clinical pregnancy outcomes. SETTING Reproductive Centre of Maternal and Child Health Hospital of Lianyungang city. INTERVENTIONS None. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome measure was CPR, the secondary outcome measure was the abortion rate. RESULTS A total of 550 IUI treatment cycles involving 275 couples were included in this study. Differences in CPR and abortion rate between the groups were not significant (20.5% vs 21.9% and 27.8% vs 22.0%, p≥0.05). Stratified analyses based on infertility factors did not reveal any significant differences in pregnancy and abortion rates between the groups (p≥0.05). Multivariate analysis showed that increased endometrial thickness correlates with CPR (OR 1.205, 95% CI 1.05 to 1.384, p=0.008). Compared with primary infertility, secondary infertility significantly correlated with improved CPR (OR 2.637, 95% CI 1.313 to 5.298, p=0.006). The effects of time interval between the first two ovulation induction IUI treatment cycles on clinical pregnancy were not significant (OR 1.007, 95% CI 0.513 to 1.974, p=0.985). CONCLUSIONS Longer time intervals between the first two ovulation induction IUI treatment cycles did not significantly improve CPR. Therefore, in the absence of clear clinical indications, it may not be necessary to deliberately prolong the interval between two ovulation induction IUI treatment cycles.
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Affiliation(s)
- Shuai Zhang
- Clinical Center of Reproductive Medicine, Lianyungang Maternal and Child Health Hospital, Lianyungang, Jiangsu, China
| | - Han-Han Tang
- Graduate School of Xuzhou Medical University, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Ming-Lian Zhou
- Clinical Center of Reproductive Medicine, Lianyungang Maternal and Child Health Hospital, Lianyungang, Jiangsu, China
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Takeshima K, Ezoe K, Kawasaki N, Hayashi H, Kuroda T, Kato K. Perinatal outcomes and congenital anomalies associated with letrozole and natural cycles in single fresh cleaved embryo transfers: A single-center, 10-year cohort study. F S Rep 2022; 3:138-144. [PMID: 35789728 PMCID: PMC9250119 DOI: 10.1016/j.xfre.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 03/01/2022] [Accepted: 03/02/2022] [Indexed: 11/03/2022] Open
Abstract
Objective To investigate and compare the safety of letrozole and natural cycles in fresh early embryo transfers. Design A retrospective cohort study. Setting A large fertility treatment center. Patient(s) Women who underwent natural and letrozole cycles during fresh early embryo transfer at Kato Ladies Clinic between January 2008 and December 2017. Intervention(s) None. Main Outcome measure(s) Perinatal complications and congenital anomalies. Result(s) No significant differences were observed in pregnancy complications, gestational age, birth weight, small for gestational age, large for gestational age, and congenital anomalies between the the women who underwent natural and letrozole cycles. Conclusion(s) The perinatal outcomes and congenital anomaly rates associated with letrozole and natural cycles in fresh early embryo transfers were comparable. Therefore, our data support the safe use of letrozole in fresh early embryo transfers in assisted reproductive technology.
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Internal validation and comparison of predictive models to determine success rate of infertility treatments: a retrospective study of 2485 cycles. Sci Rep 2022; 12:7216. [PMID: 35508641 PMCID: PMC9068696 DOI: 10.1038/s41598-022-10902-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 03/11/2022] [Indexed: 02/05/2023] Open
Abstract
Infertility is a significant health problem and assisted reproductive technologies to treat infertility. Despite all efforts, the success rate of these methods is still low. Also, each of these methods has side effects and costs. Therefore, accurate prediction of treatment success rate is a clinical challenge. This retrospective study aimed to internally validate and compare various machine learning models for predicting the clinical pregnancy rate (CPR) of infertility treatment. For this purpose, data from 1931 patients consisting of in vitro fertilization (IVF) or intra cytoplasmic sperm injection (ICSI) (733) and intra uterine insemination (IUI) (1196) treatments were included. Also, no egg or sperm donation data were used. The performance of machine learning algorithms to predict clinical pregnancy were expressed in terms of accuracy, recall, F-score, positive predictive value (PPV), brier score (BS), Matthew correlation coefficient (MCC), and receiver operating characteristic. The significance of the features with CPR and AUCs was evaluated by Student's t test and DeLong’s algorithm. Random forest (RF) model had the highest accuracy in the IVF/ICSI treatment. The sensitivity, F1 score, PPV, and MCC of the RF model were 0.76, 0.73, 0.80, and 0.5, respectively. These values for IUI treatment were 0.84, 0.80, 0.82, and 0.34, respectively. The BS was 0.13 and 0.15 for IVF/ICS and IUI, respectively. In addition, the estimated AUCs of the RF model for IVF/ICS and IUI were 0.73 and 0.7, respectively. Some essential features were obtained based on RF ranking for the two datasets, including age, follicle stimulation hormone, endometrial thickness, and infertility duration. The results showed a strong relationship between clinical pregnancy and a woman's age. Also, endometrial thickness and the number of follicles decreased with increasing female age in both treatments.
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Eleftheriadou A, Francis A, Wilcox M, Jayaprakasan K. Frozen Blastocyst Embryo Transfer: Comparison of Protocols and Factors Influencing Outcome. J Clin Med 2022; 11:jcm11030737. [PMID: 35160185 PMCID: PMC8836366 DOI: 10.3390/jcm11030737] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/19/2021] [Accepted: 01/26/2022] [Indexed: 01/27/2023] Open
Abstract
Background: Various factors, including treatment protocols, can influence the outcomes of frozen embryo transfers (FETs). The study objectives were to compare different endometrial preparation protocols of FET cycles and to evaluate the factors, including the endometrial thickness (ET), that affect outcomes. Methods: This observational cohort study involved 5037 women undergoing FETs at eight tertiary clinics in the UK between January 2016 and March 2019. The endometrial preparation protocols used were natural cycle (NC-FETs), artificial hormone support cycle with oestradiol valerate but without pituitary downregulation (AC-FETs) and artificial hormone support cycle with agonist downregulation (ACDR-FETs). Results: The mean (±SD) ages across NC-FET, AC-FET and ACDR-FET groups were 36.5 (±4.2), 35.9 (±5.0) and 36.4(±4.9) years, respectively. LBRs were comparable (40.7%, 175/430; 36.8%, 986/2658; and 36.7%, 716/1949, respectively) across the three groups. Clinical pregnancy, implantation, multiple pregnancies, miscarriage and ectopic pregnancy rates were also similar. In the regression analysis of variables including age, duration of infertility, number of embryos transferred, protocol type and endometrial thickness, age was the only significant predictor of LBRs, although its predictive ability was poor (AUC: 0.55). With the overall LBR of the study population being 37.1%, the post-test probability of a live birth at an ET of <5 mm was 0%, and at 5–5.9, 6–6.9, 7–7.9 and 8–8.9 mm, the probabilities were 16.7%, 33.8%, 36.7% and 37.7%, respectively. The LBR remained above 35% up to the 14–14.9 mm range and then declined gradually to 23% for the 17–25 mm range. Conclusions: The FET outcomes were similar for the three protocols used for endometrial preparation. The protocol type and endometrial thickness were not predictive of FET outcomes; age was the only predictive variable, despite its low predictive ability.
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Affiliation(s)
| | | | - Mark Wilcox
- CARE Fertility, Nottingham NG8 6PZ, UK; (A.F.); (M.W.)
| | - Kanna Jayaprakasan
- School of Medicine, University of Nottingham, Nottingham NG7 2RD, UK;
- CARE Fertility, Nottingham NG8 6PZ, UK; (A.F.); (M.W.)
- Correspondence:
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Jiang S, Chen L, Gao Y, Xi Q, Li W, Zhao X, Kuang Y. The Effect of Spontaneous LH Surges on Pregnancy Outcomes in Patients Undergoing Letrozole-HMG IUI: A Retrospective Analysis of 6,285 Cycles. Front Endocrinol (Lausanne) 2022; 13:880538. [PMID: 35600574 PMCID: PMC9114301 DOI: 10.3389/fendo.2022.880538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/01/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND To date, no consensus has been reached on whether to wait for spontaneous luteinizing hormone (LH) surge to occur or to trigger ovulation regardless of the presence of an LH surge for achieving higher success rate in intrauterine insemination (IUI) cycles. Therefore, we hope to investigate the effect of the presence of a spontaneous LH surge on pregnancy outcomes in letrozole-human menopausal gonadotropin (LE-HMG) IUI cycles. METHODS In this retrospective cohort study, a total of 6,285 LE-HMG IUI cycles were included between January 2010 and May 2021. Cycles were categorized into three groups: the trigger + LH surge group, the trigger only group, and the LH surge only group. The primary outcome measure was the clinical pregnancy rate. A logistic regression analysis was performed to explore other risk factors affecting the clinical pregnancy rate. RESULTS No significant differences were observed in biochemical pregnancy rate (P =0.640), clinical pregnancy rate (P =0.702), ongoing pregnancy rate (P =0.842), and live birth rate (P =0.951) among the three groups. The binary logistic regression analysis also confirmed that the existence of an LH surge was not associated with clinical pregnancy. There was a difference in ectopic pregnancy rates (P =0.045), but logistic regression showed that the presence of a spontaneous LH surge has no association with ectopic pregnancy. Nonetheless, patients with lead follicles within 18.1-20.0 mm/20.1-22.0 mm and a long duration of LE treatment were less likely to get ectopic pregnant compared with patients with 14.1-16.0 mm lead follicles and shorter LE treatment (OR: 0.142, 95% CI: 0.023-0.891, P =0.037; OR: 0.142, 95% CI: 0.022-0.903, P =0.039; OR: 0.445, 95% CI: 0.235-0.840, P = 0.013). CONCLUSIONS The presence of a spontaneous LH surge in triggered LE-HMG IUI cycles does not appear to improve pregnancy rates. Thus, we suggest that waiting for an LH surge to occur is not necessary in triggered LE-HMG IUI cycles.
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Hawkins Bressler L, Fritz MA, Wu SP, Yuan L, Kafer S, Wang T, DeMayo FJ, Young SL. Poor Endometrial Proliferation After Clomiphene is Associated With Altered Estrogen Action. J Clin Endocrinol Metab 2021; 106:2547-2565. [PMID: 34058008 PMCID: PMC8372647 DOI: 10.1210/clinem/dgab381] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Indexed: 12/25/2022]
Abstract
CONTEXT Suboptimal endometrial thickening is associated with lower pregnancy rates and occurs in some infertile women treated with clomiphene. OBJECTIVE To examine cellular and molecular differences in the endometrium of women with suboptimal vs optimal endometrial thickening following clomiphene. METHODS Translational prospective cohort study from 2018 to 2020 at a university-affiliated clinic. Reproductive age women with unexplained infertility treated with 100 mg of clomiphene on cycle days 3 to 7 who developed optimal (≥8mm; n = 6, controls) or suboptimal (<6mm; n = 7, subjects) endometrial thickness underwent preovulatory blood and endometrial sampling. The main outcome measures were endometrial tissue architecture, abundance and location of specific proteins, RNA expression, and estrogen receptor (ER) α binding. RESULTS The endometrium of suboptimal subjects compared with optimal controls was characterized by a reduced volume of glandular epithelium (16% vs 24%, P = .01), decreased immunostaining of markers of proliferation (PCNA, ki67) and angiogenesis (PECAM-1), increased immunostaining of pan-leukocyte marker CD45 and ERβ, but decreased ERα immunostaining (all P < .05). RNA-seq identified 398 differentially expressed genes between groups. Pathway analysis of differentially expressed genes indicated reduced proliferation (Z-score = -2.2, P < .01), decreased angiogenesis (Z-score = -2.87, P < .001), increased inflammation (Z-score = +2.2, P < .01), and ERβ activation (Z-score = +1.6, P < .001) in suboptimal subjects. ChIP-seq identified 6 genes bound by ERα that were differentially expressed between groups (P < .01), some of which may play a role in implantation. CONCLUSION Women with suboptimal endometrial thickness after clomiphene exhibit aberrant ER expression patterns, architectural changes, and altered gene and protein expression suggesting reduced proliferation and angiogenesis in the setting of increased inflammation.
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Affiliation(s)
- Leah Hawkins Bressler
- Department of Obstetrics & Gynecology, Division of Reproductive Endocrinology & Infertility, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Marc A Fritz
- Department of Obstetrics & Gynecology, Division of Reproductive Endocrinology & Infertility, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - San-Pin Wu
- Reproductive and Developmental Biology Laboratory, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA
| | - Lingwen Yuan
- Reproductive and Developmental Biology Laboratory, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA
| | - Suzanna Kafer
- Reproductive and Developmental Biology Laboratory, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA
| | - Tianyuan Wang
- Integrative Bioinformatics Support Group, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA
| | - Francesco J DeMayo
- Reproductive and Developmental Biology Laboratory, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA
| | - Steven L Young
- Department of Obstetrics & Gynecology, Division of Reproductive Endocrinology & Infertility, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Kabukçu C, Çabuş Ü, Öztekin Ö, Fenkçi V. The strain rate of endometrium measured by real-time sonoelastography as a predictive marker for pregnancy in gonadotropin stimulated intrauterine insemination cycles. J Obstet Gynaecol Res 2021; 47:3561-3570. [PMID: 34254413 DOI: 10.1111/jog.14921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 05/19/2021] [Accepted: 06/26/2021] [Indexed: 12/16/2022]
Abstract
AIM Sonoelastography is an imaging technique that measures tissue strain quantitatively. This study aims to investigate whether the strain rate of endometrium measured by elastography can predict pregnancy after intrauterine insemination (IUI). METHODS This study examined 197 gonadotropin-stimulated IUI cycles of 148 women diagnosed with unexplained infertility from February 2019 to November 2020. Endometrial thickness, pattern, and strain rate were measured by transvaginal ultrasonography immediately before the insemination. The endometrium and the parametrial tissue were selected for regions of interest, and the strain rate was calculated. The measurements were analyzed concerning the IUI outcome. RESULTS Of the 197 IUI cycles, the pregnancy rate was 15.20% (n = 30), and ongoing pregnancy rate was 12.2% (n = 24). The mean strain rates were not different between pregnant and nonpregnant groups (2.68 ± 1.28 vs. 2.81 ± 1.32, p = 0.651). Strain rate was not predictive for pregnancy, shown by receiver operating characteristic curve analysis; the area under the curve was 0.526 (95% CI 0.413-0.639; p = 0.649). Pregnancy rates were significantly affected by the women's age and the inseminated sperm count. In multiple logistic regression analysis, the other parameters, including body mass index, anti-Müllerian hormone, endometrial thickness, endometrial strain rate, and echogenic endometrial pattern, did not significantly change the odds ratio of pregnancy. CONCLUSION The endometrial strain rate does not significantly affect the pregnancy rates in gonadotropin stimulated IUI cycles. It appears that strain rate does not predict IUI outcome. More research is needed to evaluate the usefulness of sonoelastography in infertility treatments.
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Affiliation(s)
- Cihan Kabukçu
- Faculty of Medicine, Department of Obstetrics and Gynecology, Pamukkale University, Denizli, Turkey
| | - Ümit Çabuş
- Faculty of Medicine, Department of Obstetrics and Gynecology, Pamukkale University, Denizli, Turkey
| | - Özer Öztekin
- Faculty of Medicine, Department of Obstetrics and Gynecology, Pamukkale University, Denizli, Turkey
| | - Veysel Fenkçi
- Faculty of Medicine, Department of Obstetrics and Gynecology, Pamukkale University, Denizli, Turkey
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Xu B, Cao Y, Zheng Z, Galan EA, Hu Z, Ge J, Xing X, Ma S. Injectable Mesenchymal Stem Cell-Laden Matrigel Microspheres for Endometrium Repair and Regeneration. Adv Biol (Weinh) 2021; 5:e2000202. [PMID: 34117721 DOI: 10.1002/adbi.202000202] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 05/04/2021] [Indexed: 12/14/2022]
Abstract
Endometrial injury and intrauterine adhesions are increasingly reported in recent years; however, treatment options remain limited. Intravenous injection of mesenchymal stem cells (MSCs) for endometrium regeneration has limited effectiveness as the retention rate of transplanted cells is low. Hydrogel-based tissue-engineered solutions, such as MSC-seeded bioscaffolds, are reported to increase retention rates; however, a less invasive alternative is still desirable. 560-µm homogeneous Matrigel microspheres are fabricated, loading them with about 1500 MSCs and injecting them into the injured endometria of rats' uteri. This minimally invasive procedure is proved to significantly increase endometrium thickness by over onefold after 21 d (p < 0.0001) and fertility rates from 25% to 75% in impaired and repaired uteri (p < 0.001), respectively. This study provides a minimally invasive alternative to endometrium repair with the promise to establish a broad-spectrum technique for MSC transplantation.
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Affiliation(s)
- Bing Xu
- Tsinghua-Berkeley Shenzhen Institute (TBSI), Tsinghua University, Shenzhen, 518055, China.,Tsinghua Shenzhen International Graduate School (SIGS), Tsinghua University, Shenzhen, 518055, China
| | - Yuanxiong Cao
- Tsinghua-Berkeley Shenzhen Institute (TBSI), Tsinghua University, Shenzhen, 518055, China.,Tsinghua Shenzhen International Graduate School (SIGS), Tsinghua University, Shenzhen, 518055, China
| | - Zheng Zheng
- Shenzhen Maternity and Child Healthcare Hospital, 2004 Hongli Road, Shenzhen, 518028, China
| | - Edgar A Galan
- Tsinghua-Berkeley Shenzhen Institute (TBSI), Tsinghua University, Shenzhen, 518055, China.,Tsinghua Shenzhen International Graduate School (SIGS), Tsinghua University, Shenzhen, 518055, China
| | - Zhiwei Hu
- Tsinghua-Berkeley Shenzhen Institute (TBSI), Tsinghua University, Shenzhen, 518055, China.,Tsinghua Shenzhen International Graduate School (SIGS), Tsinghua University, Shenzhen, 518055, China
| | - Jun Ge
- Tsinghua Shenzhen International Graduate School (SIGS), Tsinghua University, Shenzhen, 518055, China.,Department of Chemical Engineering, Tsinghua University, Beijing, 100084, China
| | - Xinhui Xing
- Tsinghua Shenzhen International Graduate School (SIGS), Tsinghua University, Shenzhen, 518055, China.,Department of Chemical Engineering, Tsinghua University, Beijing, 100084, China
| | - Shaohua Ma
- Tsinghua-Berkeley Shenzhen Institute (TBSI), Tsinghua University, Shenzhen, 518055, China.,Tsinghua Shenzhen International Graduate School (SIGS), Tsinghua University, Shenzhen, 518055, China
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Li Q, Zhu M, Deng Z, Wang L, Huang Y, Ruan L, Hu S, Wang L. Effect of gonadotropins and endometrial thickness on pregnancy outcome in patients with unexplained infertility or polycystic ovarian syndrome undergoing intrauterine insemination. J Int Med Res 2021; 48:300060520966538. [PMID: 33121310 PMCID: PMC7607295 DOI: 10.1177/0300060520966538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective The purpose of this study was to investigate the effect of gonadotropin dose
and endometrial thickness (EMT) on pregnancy outcome in patients undergoing
intrauterine insemination (IUI). Methods We retrospectively analyzed data from 361 patients with unexplained
infertility or polycystic ovarian syndrome (PCOS) who underwent 930 IUI
cycles treated with gonadotropins. Then, we measured the effects of
gonadotropins and EMT on the clinical pregnancy rate. Finally, we assessed
the association of various doses of gonadotropins on EMT. Results The dose of gonadotropins given and thickness of the endometrium were higher
in the pregnancy group than in the nonpregnancy group (636.0 vs. 600.0 IU
for gonadotropin dose; 9.15 vs. 8.70 mm for EMT). Clinical pregnancy rates
were significantly improved by increasing the dose of gonadotropins (9.1%,
<450 IU; 16.2%, 450–599 IU; 18.6%, 600–749 IU, and 17.3%, ≥750 IU), or by
increased EMT (0%, <5.0 mm; 12.2%, 5.0–6.9 mm; 15.5%, 7.0–14.0 mm; and
33.3%, >14.0 mm). Conclusion Increasing the dose of gonadotropins to stimulate one follicle to develop may
benefit endometrial proliferation and improve IUI outcomes.
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Affiliation(s)
- Qing Li
- Reproductive Medicine Center, Nanning Maternal and Child Health Care Hospital, Nanning, China.,College of Biotechnology, Guilin Medical University, Guilin, Guangxi, China
| | - Maoling Zhu
- Reproductive Medicine Center, Nanning Maternal and Child Health Care Hospital, Nanning, China
| | - Zhuxiu Deng
- Reproductive Medicine Center, Nanning Maternal and Child Health Care Hospital, Nanning, China
| | - Lihua Wang
- Department of Paediatrics, Tianlin People's Hospital, Baise, China
| | - Yi Huang
- Reproductive Medicine Center, Nanning Maternal and Child Health Care Hospital, Nanning, China
| | - Liming Ruan
- Reproductive Medicine Center, Nanning Maternal and Child Health Care Hospital, Nanning, China
| | - Shaofei Hu
- Reproductive Medicine Center, Nanning Maternal and Child Health Care Hospital, Nanning, China
| | - Liping Wang
- College of Biotechnology, Guilin Medical University, Guilin, Guangxi, China
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30
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Bordewijk EM, Weiss NS, Nahuis MJ, Kwee J, Lambeek AF, van Unnik GA, Vrouenraets FPJ, Cohlen BJ, van de Laar-van Asseldonk TAM, Lambalk CB, Goddijn M, Hompes PG, van der Veen F, Mol BWJ, van Wely M. Gonadotrophins or clomiphene citrate in women with normogonadotropic anovulation and CC failure: does the endometrium matter? Hum Reprod 2021; 35:1319-1324. [PMID: 32585686 PMCID: PMC7316496 DOI: 10.1093/humrep/deaa052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 12/20/2019] [Indexed: 11/23/2022] Open
Abstract
STUDY QUESTION Is endometrial thickness (EMT) a biomarker to select between women who should switch to gonadotropins and those who could continue clomiphene citrate (CC) after six failed ovulatory cycles? SUMMARY ANSWER Using a cut-off of 7 mm for EMT, we can distinguish between women who are better off switching to gonadotropins and those who could continue CC after six earlier failed ovulatory CC cycles. WHAT IS ALREADY KNOWN For women with normogonadotropic anovulation, CC has been a long-standing first-line treatment in conjunction with intercourse or intrauterine insemination (IUI). We recently showed that a switch to gonadotropins increases the chance of live birth by 11% in these women over continued treatment with CC after six failed ovulatory cycles, at a cost of €15 258 per additional live birth. It is unclear whether EMT can be used to identify women who can continue on CC with similar live birth rates without the extra costs of gonadotropins. STUDY DESIGN, SIZE, DURATION Between 8 December 2008 and 16 December 2015, 666 women with CC failure were randomly assigned to receive an additional six cycles with a change to gonadotropins (n = 331) or an additional six cycles continuing with CC (n = 335), both in conjunction with intercourse or IUI. The primary outcome was conception leading to live birth within 8 months after randomisation. EMT was measured mid-cycle before randomisation during their sixth ovulatory CC cycle. The EMT was available in 380 women, of whom 190 were allocated to gonadotropins and 190 were allocated to CC. PARTICIPANTS/MATERIALS, SETTING, METHODS EMT was determined in the sixth CC cycle prior to randomisation. We tested for interaction of EMT with the treatment effect using logistic regression. We performed a spline analysis to evaluate the association of EMT with chance to pregnancy leading to a live birth in the next cycles and to determine the best cut-off point. On the basis of the resulting cut-off point, we calculated the relative risk and 95% CI of live birth for gonadotropins versus CC at EMT values below and above this cut-off point. Finally, we calculated incremental cost-effectiveness ratios (ICER). MAIN RESULTS AND THE ROLE OF CHANCE Mid-cycle EMT in the sixth cycle interacted with treatment effect (P < 0.01). Spline analyses showed a cut-off point of 7 mm. There were 162 women (45%) who had an EMT ≤ 7 mm in the sixth ovulatory cycle and 218 women (55%) who had an EMT > 7 mm. Among the women with EMT ≤ 7 mm, gonadotropins resulted in a live birth in 44 of 79 women (56%), while CC resulted in a live birth in 28 of 83 women (34%) (RR 1.57, 95% CI 1.13–2.19). Per additional live birth with gonadotropins, the ICER was €9709 (95% CI: €5117 to €25 302). Among the women with EMT > 7 mm, gonadotropins resulted in a live birth in 53 of 111 women (48%) while CC resulted in a live birth in 52 of 107 women (49%) (RR 0.98, 95% CI 0.75–1.29). LIMITATIONS, REASONS FOR CAUTION This was a post hoc analysis of a randomised controlled trial (RCT) and therefore mid-cycle EMT measurements before randomisation during their sixth ovulatory CC cycle were not available for all included women. WIDER IMPLICATIONS OF THE FINDINGS In women with six failed ovulatory cycles on CC and an EMT ≤ 7 mm in the sixth cycle, we advise switching to gonadotropins, since it improves live birth rate over continuing treatment with CC at an extra cost of €9709 to achieve one additional live birth. If the EMT > 7 mm, we advise to continue treatment with CC, since live birth rates are similar to those with gonadotropins, without the extra costs. STUDY FUNDING/COMPETING INTEREST(S) The original MOVIN trial received funding from the Dutch Organization for Health Research and Development (ZonMw number: 80-82310-97-12067). C.B.L.A. reports unrestricted grant support from Merck and Ferring. B.W.M. is supported by a NHMRC Practitioner Fellowship (GNT1082548) and reports consultancy for Merck, ObsEva, IGENOMIX and Guerbet. All other authors have nothing to declare. TRIAL REGISTRATION NUMBER Netherlands Trial Register, number NTR1449
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Affiliation(s)
- E M Bordewijk
- Center for Reproductive Medicine Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - N S Weiss
- Center for Reproductive Medicine Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands.,Center for Reproductive Medicine Amsterdam UMC, VU University, De Boelelaan 1117, Amsterdam, Netherlands
| | - M J Nahuis
- Department of Obstetrics and Gynaecology, Noordwest Ziekenhuisgroep, Alkmaar, Netherlands
| | - J Kwee
- Department of Obstetrics and Gynaecology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - A F Lambeek
- Department of Obstetrics and Gynaecology, IJsselland Hospital, Capelle aan den Ijssel, Netherlands
| | - G A van Unnik
- Department of Obstetrics and Gynaecology, Alrijne Hospital, Leiden, Netherlands
| | - F P J Vrouenraets
- Department of Obstetrics and Gynaecology, Zuyderland Medical Center, Heerlen, Netherlands
| | - B J Cohlen
- Department of Obstetrics and Gynaecology, Isala Fertility Center, Zwolle, Netherlands
| | | | - C B Lambalk
- Center for Reproductive Medicine Amsterdam UMC, VU University, De Boelelaan 1117, Amsterdam, Netherlands
| | - M Goddijn
- Center for Reproductive Medicine Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - P G Hompes
- Center for Reproductive Medicine Amsterdam UMC, VU University, De Boelelaan 1117, Amsterdam, Netherlands
| | - F van der Veen
- Center for Reproductive Medicine Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - B W J Mol
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - M van Wely
- Center for Reproductive Medicine Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
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Xu XL, Deng SL, Lian ZX, Yu K. Estrogen Receptors in Polycystic Ovary Syndrome. Cells 2021; 10:cells10020459. [PMID: 33669960 PMCID: PMC7924872 DOI: 10.3390/cells10020459] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 12/13/2022] Open
Abstract
Female infertility is mainly caused by ovulation disorders, which affect female reproduction and pregnancy worldwide, with polycystic ovary syndrome (PCOS) being the most prevalent of these. PCOS is a frequent endocrine disease that is associated with abnormal function of the female sex hormone estrogen and estrogen receptors (ERs). Estrogens mediate genomic effects through ERα and ERβ in target tissues. The G-protein-coupled estrogen receptor (GPER) has recently been described as mediating the non-genomic signaling of estrogen. Changes in estrogen receptor signaling pathways affect cellular activities, such as ovulation; cell cycle phase; and cell proliferation, migration, and invasion. Over the years, some selective estrogen receptor modulators (SERMs) have made substantial strides in clinical applications for subfertility with PCOS, such as tamoxifen and clomiphene, however the role of ER in PCOS still needs to be understood. This article focuses on the recent progress in PCOS caused by the abnormal expression of estrogen and ERs in the ovaries and uterus, and the clinical application of related targeted small-molecule drugs.
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Affiliation(s)
- Xue-Ling Xu
- College of Animal Science and Technology, China Agricultural University, Beijing 100193, China;
| | - Shou-Long Deng
- Institute of Laboratory Animal Sciences, Chinese Academy of Medical Sciences, Ministry of Health, Beijing 100021, China;
- CAS Key Laboratory of Genome Sciences and Information, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing 100101, China
| | - Zheng-Xing Lian
- College of Animal Science and Technology, China Agricultural University, Beijing 100193, China;
- Correspondence: (Z.-X.L.); (K.Y.)
| | - Kun Yu
- College of Animal Science and Technology, China Agricultural University, Beijing 100193, China;
- Correspondence: (Z.-X.L.); (K.Y.)
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32
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Optimal lead follicle size for human chorionic gonadotropin trigger in clomiphene citrate and intrauterine insemination cycles: an analysis of 1,676 treatment cycles. Fertil Steril 2020; 115:984-990. [PMID: 33272641 DOI: 10.1016/j.fertnstert.2020.10.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 05/21/2020] [Accepted: 10/02/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To identify the optimal lead follicle size for hCG trigger in clomiphene citrate (CC)-intrauterine insemination (IUI) cycles. DESIGN Retrospective cohort study. SETTING University-affiliated center. PATIENT(S) Patients <40 years of age with ovulatory dysfunction or unexplained infertility undergoing their first CC-IUI cycle. INTERVENTION(S) Ovulation induction, hCG trigger, and IUI. MAIN OUTCOME MEASURE(S) Clinical pregnancy rate (CPR) was the primary outcome and was plotted against lead follicle size in increments of 1 mm. Odds ratios with 95% confidence intervals for associations between lead follicle size and CPR were calculated from a multivariable logistic regression model. A receiver operating characteristic (ROC) curve was generated for CPR as a function of lead follicle size. RESULT(S) 1,676 cycles were included. The overall CPR was 13.8% (232/1,676). There was no difference in baseline demographics or ovulation induction parameters of patients who did or did not conceive. The odds of clinical pregnancy were 2.3 and 2.2 times higher with lead follicle sizes of 21.1-22.0 mm and >22.0 mm, respectively, compared with the referent category of 19.1-20.0 mm. Lead follicle size was an independent predictor of CPR, even after accounting for confounders. A lead follicle size of 22.1 mm corresponded to a sensitivity and specificity of 80.1% and 90.4% for clinical pregnancy, respectively, with an area under the ROC curve of 0.89. CONCLUSION(S) hCG administration at a lead follicle size of 21.1-22.0 mm is associated with higher odds of clinical pregnancy in patients undergoing their first CC-IUI cycles for ovulatory dysfunction or unexplained infertility.
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33
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Elusive effect of endometrial thickness: through thick and thin. Fertil Steril 2020; 115:89-90. [PMID: 33059889 DOI: 10.1016/j.fertnstert.2020.09.135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 09/11/2020] [Indexed: 01/10/2023]
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34
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Frantz N, Ferreira M, Kulmann MI, Frantz G, Bos-Mikich A, Oliveira R. Platelet-Rich plasma as an effective alternative approach for improving endometrial receptivity - a clinical retrospective study. JBRA Assist Reprod 2020; 24:442-446. [PMID: 32293825 PMCID: PMC7558896 DOI: 10.5935/1518-0557.20200026] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Objective: The aim of the present case series was to describe our experience with the use of PRP on patients with refractory thin endometria. Methods: This retrospective analysis included 24 IVF cycles in which patients presenting different infertility factors received intrauterine PRP infusion prior to embryo transfer. Outcomes of interest were: clinical and ongoing pregnancies, miscarriages, and births. Results: 54% of the cycles in which PRP was employed resulted in ongoing gestation or birth; 12.5% of the cycles ended in miscarriages. Conclusion: Our data suggest that PRP improves intrauterine receptivity to embryo implantation, regardless of whether the endometrium reached the appropriate growth for embryo transfer.
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Affiliation(s)
- Nilo Frantz
- Nilo Frantz Medicina Reprodutiva, Porto Alegre, RS, Brazil
| | | | | | - Gerta Frantz
- Nilo Frantz Medicina Reprodutiva, Porto Alegre, RS, Brazil
| | - Adriana Bos-Mikich
- Instituto Ciências Básicas da Saúde, Universidade Federal Do Rio Grande do Sul, Brazil
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35
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Endometrial thickness after ovarian stimulation with gonadotropin, clomiphene, or letrozole for unexplained infertility, and association with treatment outcomes. Fertil Steril 2020; 115:213-220. [PMID: 32972733 DOI: 10.1016/j.fertnstert.2020.07.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To study the association of endometrial thickness (EMT) with live birth rates (LBR) in ovarian stimulation with intrauterine insemination (OS-IUI) treatments for unexplained infertility. DESIGN Prospective cohort analysis of the Reproductive Medicine Network's Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) randomized controlled trial. SETTING Multicenter randomized controlled trial. PATIENTS A total of 868 couples with unexplained infertility (n=2,459 cycles). INTERVENTIONS OS-IUI treatment cycles (n = 2,459) as part of the AMIGOS clinical trial. MAIN OUTCOME MEASURES Live birth rates; unadjusted and adjusted risk ratios (RR) for live birth by EMT category, calculated using generalized estimating equations. RESULTS The overall mean EMT on day of human chorionic gonadotropin administration in cycles with a live birth was significantly greater than in those without. Compared to the referent EMT group of 9 to 12 mm, the unadjusted RR for live birth for the EMT groups of ≤5 and 6-8 were 0.48 and 0.92, respectively. The test for trend indicated evidence of decreasing LBR with decreasing EMT. After adjustment for ovarian stimulation medication, a linear trend was no longer supported. Stratified analyses revealed no differences in associations by treatment group. CONCLUSIONS In OS-IUI for unexplained infertility, higher LBR are observed with increasing EMT; however, EMT is not significantly associated with LBR when adjusted for OS treatment type. Appreciable LBR are seen at all EMT, even those of ≤5 mm, suggesting that OS-IUI cycles should not be canceled for thin endometrium. CLINICAL TRIAL REGISTRATION NUMBER NCT01044862.
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Chen D, Shen X, Fu Y, Ding C, Zhong Y, Zhou C. Pregnancy Outcomes Following Letrozole Use in Frozen-thawed Embryo Transfer Cycles: A Systematic Review and Meta-analysis. Geburtshilfe Frauenheilkd 2020; 80:820-833. [PMID: 32817989 PMCID: PMC7428376 DOI: 10.1055/a-1202-2059] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 06/17/2020] [Indexed: 12/13/2022] Open
Abstract
While widely used for ovulation induction in assisted reproductive technology, the clinical efficacy of letrozole for endometrial preparation prior to frozen-thawed embryo transfer (FET) cycles remains yet to be elucidated. We performed a meta-analysis to compare pregnancy outcomes after letrozole use with those of other endometrial preparation protocols in patients undergoing FET. PubMed, Scopus, Embase and the Cochrane Library were searched for eligible studies. Clinical pregnancy rate (CPR), live birth rate (LBR) and birth defect rate (BDR) were analysed using odds ratio (OR) and 95% confidence interval (CI). A total of 10 studies representing 75 968 FET cycles were included. Comparable CPR and LBR were observed when comparing letrozole administration with natural cycle (OR 1.24, 95% CI: 0.69 – 2.24; OR 1.18, 95% CI: 0.60 – 2.32), artificial cycle (OR 1.46, 95% CI: 0.87 – 2.44; OR 1.39, 95% CI: 0.77 – 2.52), and artificial cycle with gonadotropin-releasing hormone
agonist suppression (OR 1.11, 95% CI: 0.78 – 1.59; OR 1.18, 95% CI: 0.82 – 1.68). Pooled results of the limited studies comparing letrozole with human menopausal gonadotropin demonstrated a similar CPR between groups (OR 1.46, 95% CI: 0.29 – 7.21, two studies), but the letrozole group had a statistically lower LBR (OR 0.67, 95% CI: 0.52 – 0.86, one study). No increased BDR was observed in the letrozole group compared to natural cycles or artificial cycles (OR 0.98, 95% CI: 0.60 – 1.61; OR 1.39, 95% CI; 0.84 – 2.28). This pooled analysis supports the use of letrozole as an efficacious and safe alternative to mainstream regimens for endometrial preparation in FET cycles.
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Affiliation(s)
- Dongjia Chen
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
| | - Xiaoting Shen
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
| | - Yu Fu
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
| | - Chenhui Ding
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
| | - Yiping Zhong
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
| | - Canquan Zhou
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
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Huang J, Lin J, Lu X, Gao H, Song N, Cai R, Kuang Y. Association between endometrial thickness and neonatal outcomes in intrauterine insemination cycles: a retrospective analysis of 1,016 live-born singletons. Reprod Biol Endocrinol 2020; 18:48. [PMID: 32410619 PMCID: PMC7222451 DOI: 10.1186/s12958-020-00597-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 04/22/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Decreased endometrial thickness (EMT) has been suggested to be associated with reduced birthweight of in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) newborns. Considering the differences in ovarian stimulation degree and laboratory procedures between IVF/ICSI and IUI treatment, we aim to investigate whether EMT has any influence on IUI infant outcomes as well. METHODS This was a retrospective cohort study of 1016 patients who had singleton livebirths after IUI treatment cycles from January 2008 to December 2018 at a tertiary-care academic medical center in China. Patients were categorized into three groups by the 10th and 90th percentile of peak EMT: ≤7.6, 7.7-13.0 and ≥ 13.1 mm. The primary outcomes of the study were preterm birth (PTB), low birthweight (LBW) and small-for-gestational age (SGA). Multiple regression analyses were performed after controlling for a variety of potential confounders. RESULTS No significant differences were found among the three groups in gestational age, birthweight and birthweight Z-score. Compared with the EMT 7.7-13.0 mm group, the incidences of PTB, LBW and SGA were 5.5% (adjusted odds ratio [aOR] 0.81, 95% confidence interval [CI] 0.33-2.01), 6.4% (aOR 1.44, 95% CI 0.58-3.58) and 7.3% (aOR 1.21, 95% CI 0.53-2.76) in the EMT ≤7.6 mm group, respectively. Similarly, EMT ≥13.1 mm was not significantly associated with risks of PTB (aOR 0.63, 95% CI 0.24-1.65), LBW (aOR 0.57, 95% CI 0.17-1.95) and SGA (aOR 0.73, 95% CI 0.28-1.92). The odds of other adverse neonatal outcomes, including macrosomia, large-for-gestational age and major congenital malformations, did not show significant differences before and after adjustment in both EMT ≤7.6 and ≥ 13.1 mm groups. CONCLUSIONS EMT is not independently associated with adverse perinatal outcomes in IUI cycles. This novel finding would provide reassuring information for IUI patients with thin endometrial linings regarding their neonatal health. However, further prospective cohort studies with larger datasets are needed to confirm the conclusion.
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Affiliation(s)
- Jialyu Huang
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Rd, Shanghai, 200011, China
| | - Jiaying Lin
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Rd, Shanghai, 200011, China
| | - Xuefeng Lu
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Rd, Shanghai, 200011, China
| | - Hongyuan Gao
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Rd, Shanghai, 200011, China
| | - Ning Song
- Department of Histology, Embryology, Genetics and Developmental Biology, Shanghai Key Laboratory for Reproductive Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Renfei Cai
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Rd, Shanghai, 200011, China.
| | - Yanping Kuang
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Rd, Shanghai, 200011, China.
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Craciunas L, Gallos I, Chu J, Bourne T, Quenby S, Brosens JJ, Coomarasamy A. Conventional and modern markers of endometrial receptivity: a systematic review and meta-analysis. Hum Reprod Update 2020; 25:202-223. [PMID: 30624659 DOI: 10.1093/humupd/dmy044] [Citation(s) in RCA: 242] [Impact Index Per Article: 60.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 10/31/2018] [Accepted: 12/04/2018] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Early reproductive failure is the most common complication of pregnancy with only 30% of conceptions reaching live birth. Establishing a successful pregnancy depends upon implantation, a complex process involving interactions between the endometrium and the blastocyst. It is estimated that embryos account for one-third of implantation failures, while suboptimal endometrial receptivity and altered embryo-endometrial dialogue are responsible for the remaining two-thirds. Endometrial receptivity has been the focus of extensive research for over 80 years, leading to an indepth understanding of the processes associated with embryo-endometrial cross-talk and implantation. However, little progress has been achieved to translate this understanding into clinically meaningful prognostic tests and treatments for suboptimal endometrial receptivity. OBJECTIVE AND RATIONALE The objective of this systematic review was to examine the evidence from observational studies supporting the use of endometrial receptivity markers as prognostic factors for pregnancy outcome in women wishing to conceive, in order to aid clinicians in choosing the most useful marker in clinical practice and for informing further research. SEARCH METHODS The review protocol was registered with PROSPERO (CRD42017077891). MEDLINE and Embase were searched for observational studies published from inception until 26 February 2018. We included studies that measured potential markers of endometrial receptivity prior to pregnancy attempts and reported the subsequent pregnancy outcomes. We performed association and accuracy analyses using clinical pregnancy as an outcome to reflect the presence of receptive endometrium. The Newcastle-Ottawa scale for observational studies was employed to assess the quality of the included studies. OUTCOMES We included 163 studies (88 834 women) of moderate overall quality in the narrative synthesis, out of which 96 were included in the meta-analyses. Studies reported on various endometrial receptivity markers evaluated by ultrasound, endometrial biopsy, endometrial fluid aspirate and hysteroscopy in the context of natural conception, IUI and IVF. Associations were identified between clinical pregnancy and various endometrial receptivity markers (endometrial thickness, endometrial pattern, Doppler indices, endometrial wave-like activity and various molecules); however, their poor ability to predict clinical pregnancy prevents them from being used in clinical practice. Results from several modern molecular tests are promising and further data are awaited. WIDER IMPLICATIONS The post-test probabilities from our analyses may be used in clinical practice to manage couples' expectations during fertility treatments (IUI and IVF). Conventionally, endometrial receptivity is seen as a dichotomous outcome (present or absent), but we propose that various levels of endometrial receptivity exist within the window of implantation. For instance, different transcriptomic signatures could represent varying levels of endometrial receptivity, which can be linked to different pregnancy outcomes. Many studies reported the means of a particular biomarker in those who achieved a pregnancy compared with those who did not. However, extreme values of a biomarker (as opposite to the means) may have significant prognostic and diagnostic implications that are not captured in the means. Therefore, we suggest reporting the outcomes by categories of biomarker levels rather than reporting means of biomarker levels within clinical outcome groups.
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Affiliation(s)
- Laurentiu Craciunas
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Ioannis Gallos
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Justin Chu
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Tom Bourne
- Tommy's National Centre for Miscarriage Research, Imperial College London, London, UK
| | - Siobhan Quenby
- Tommy's National Centre for Miscarriage Research, University of Warwick, Coventry, UK
| | - Jan J Brosens
- Tommy's National Centre for Miscarriage Research, University of Warwick, Coventry, UK
| | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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Danhof NA, van Eekelen R, Repping S, Mol BWJ, van der Veen F, van Wely M, Mochtar MH. Endometrial thickness as a biomarker for ongoing pregnancy in IUI for unexplained subfertility: a secondary analysis. Hum Reprod Open 2020; 2020:hoz024. [PMID: 31934648 PMCID: PMC6946937 DOI: 10.1093/hropen/hoz024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 08/12/2019] [Indexed: 12/28/2022] Open
Abstract
STUDY QUESTION What is, in couples with unexplained subfertility undergoing IUI, the impact of gonadotrophins compared to clomiphene citrate (CC) on endometrial thickness (EMT) in relation to ongoing pregnancy? SUMMARY ANSWER In women with unexplained subfertility undergoing IUI with ovarian stimulation, gonadotrophins lead to a thicker endometrium compared to CC, but this does not affect ongoing pregnancy rates. WHAT IS KNOWN ALREADY A systematic review and meta-analysis among couples with unexplained subfertility undergoing IUI with ovarian stimulation showed that women who conceived had, on average, a thicker endometrium than women who did not conceive, but this evidence is not robust due to a high level of heterogeneity. There was insufficient data to draw any conclusions on EMT and the effect on pregnancy outcomes. STUDY DESIGN SIZE DURATION We performed a secondary analysis of a multicentre randomized controlled superiority trial in couples with unexplained subfertility undergoing IUI with adherence to strict cancellation criteria. In total, 738 couples recruited between July 2013 and March 2016 were allocated to ovarian stimulation with gonadotrophins (n = 369) or with CC (n = 369) for a maximum of four IUI cycles. According to local protocol, recombinant FSH, urinary FSH or hMG was used. Natural conceptions and cancelled cycles were removed from this secondary analysis, as they do not provide any information on pregnancy in relation to stimulation after IUI. Ongoing pregnancy was defined as a positive heartbeat at or beyond 12 weeks of gestation. PARTICIPANTS/MATERIALS SETTING METHODS We first determined the difference in EMT between women randomized to gonadotrophins (75 IU) and CC (100 mg) over all cycles using a linear mixed model. We then investigated the association between EMT and ongoing pregnancy after IUI using a logistic regression model, adjusted for the allocated drug, number of dominant follicles, female age, BMI, duration of subfertility, primary or secondary subfertility, referral status, smoking status, cycle number and total motile sperm count. To conclude, we investigated the association between EMT and ongoing pregnancy by logistic regression separately in women allocated to gonadotrophins and in women allocated to CC. MAIN RESULTS AND THE ROLE OF CHANCE A total of 666 couples underwent 1968 IUI cycles. Of these, 330 couples were allocated to gonadotrophins, of which 85 conceived leading to ongoing pregnancy (rate per cycle 8.9%) and 336 couples were allocated to CC, of which 71 conceived leading to ongoing pregnancy (rate per cycle 7.0%) (relative risk (RR) 1.22, 95% CI 0.92 to 1.61). The mean EMT was 8.9 mm (SD 2.1) in women treated with gonadotrophins and 7.5 mm (SD 2.1) in women treated with CC (adjusted mean difference 1.4 mm; 95% CI: 1.1-1.7). The overall mean EMT was 8.4 mm (SD 2.2) in women that conceived leading to ongoing pregnancy and 8.2 mm (SD 2.2) in women that did not conceive (adjusted odds ratio (OR): 1.03 per 1 mm increase, 95% CI 0.95-1.12). There was no association between EMT and ongoing pregnancy in women treated with gonadotrophins or CC (OR: 1.01 per 1 mm increase, 95% CI 0.90-1.13, and 1.10 per 1 mm increase, 95% CI 0.99-1.23, respectively). LIMITATIONS REASON FOR CAUTION Since this is a secondary analysis, the data should be interpreted prudently as secondary analyses are prone to false-positive findings or could be underpowered to show associations that the study is not primarily set up for. WIDER IMPLICATIONS OF THE FINDINGS In women with unexplained subfertility and treated with IUI, gonadotrophins lead to a significantly thicker endometrium compared to CC, but there was no evidence of a consistent association between EMT in women treated with gonadotrophins or CC and the ongoing pregnancy rate. A relatively thin endometrium after CC is therefore not a valid reason to prefer gonadotrophins as the stimulation agent in IUI for unexplained subfertility. STUDY FUNDING/COMPETING INTERESTS The initial trial was funded by the Netherlands Organization for Health Research and Development (ZonMw) (Health Care Efficiency Research; project number: 80-83600-98-10 192). The EudraCT number for this trial was 2013-001034-18. Prof. Dr B.W.J.M. is supported by a NHMRC Practitioner Fellowship (GNT1082548). B.W.M. reports consultancy for Merck, ObsEva and Guerbet. The other authors declare no conflicts of interest. TRIAL REGISTRATION NUMBER NTR 4057.
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Affiliation(s)
- N A Danhof
- Centre for Reproductive Medicine, Academic Medical Centre, Amsterdam, the Netherlands
| | - R van Eekelen
- Centre for Reproductive Medicine, Academic Medical Centre, Amsterdam, the Netherlands
| | - S Repping
- Centre for Reproductive Medicine, Academic Medical Centre, Amsterdam, the Netherlands
| | - B W J Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria; Australia
| | - F van der Veen
- Centre for Reproductive Medicine, Academic Medical Centre, Amsterdam, the Netherlands
| | - M van Wely
- Centre for Reproductive Medicine, Academic Medical Centre, Amsterdam, the Netherlands
| | - M H Mochtar
- Centre for Reproductive Medicine, Academic Medical Centre, Amsterdam, the Netherlands
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Meng J, Zhu M, Shen W, Huang X, Sun H, Zhou J. Influence of surgical evacuation on pregnancy outcomes of subsequent embryo transfer cycle following miscarriage in an initial IVF cycle: a retrospective cohort study. BMC Pregnancy Childbirth 2019; 19:409. [PMID: 31703714 PMCID: PMC6839260 DOI: 10.1186/s12884-019-2543-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 09/30/2019] [Indexed: 12/02/2022] Open
Abstract
Background It is still uncertain whether surgical evacuation adversely affects subsequent embryo transfer. The present study aims to assess the influence of surgical evacuation on the pregnancy outcomes of subsequent embryo transfer cycle following first trimester miscarriage in an initial in vitro fertilization and embryo transfer (IVF-ET) cycle. Methods A total of 645 patients who underwent their first trimester miscarriage in an initial IVF cycle between January 2013 and May 2016 in Nanjing Drum Tower Hospital were enrolled. Surgical evacuation was performed when the products of conception were retained more than 8 h after medical evacuation. Characteristics and pregnancy outcomes were compared between surgical evacuation patients and no surgical evacuation patients. The pregnancy outcomes following surgical evacuation were further compared between patients with ≥ 8 mm or < 8 mm endometrial thickness (EMT), and with the different EMT changes. Results The EMT in the subsequent embryo transfer cycle of surgical evacuation group was much thinner when compared with that in the no surgical evacuation group (9.0 ± 1.6 mm vs. 9.4 ± 1.9 mm, P = 0.01). There was no significant difference in implantation rate, clinical pregnancy rate, live birth rate or miscarriage rate between surgical evacuation group and no surgical evacuation group (P > 0.05). The live birth rate was higher in EMT ≥ 8 mm group when compared to < 8 mm group in surgical evacuation patients (43.0% vs. 17.4%, P < 0.05). Conclusions There was no significant difference in the pregnancy outcomes of subsequent embryo transfer cycle between surgical evacuation patients and no surgical evacuation patients. Surgical evacuation led to the decrease of EMT, especially when the EMT < 8 mm was association with a lower live birth rate.
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Affiliation(s)
- Junan Meng
- Reproductive Medicine Center, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Zhongshan Road 321#, Nanjing, 210008, People's Republic of China
| | - Mengchen Zhu
- Reproductive Medicine Center, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Zhongshan Road 321#, Nanjing, 210008, People's Republic of China
| | - Wenjuan Shen
- Department of Obstetrics and Gynecology, Suqian People's Hospital of Drum Tower Hospital Group, Suqian, 223800, China
| | - Xiaomin Huang
- Reproductive Medicine Center, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Zhongshan Road 321#, Nanjing, 210008, People's Republic of China
| | - Haixiang Sun
- Reproductive Medicine Center, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Zhongshan Road 321#, Nanjing, 210008, People's Republic of China.
| | - Jianjun Zhou
- Reproductive Medicine Center, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Zhongshan Road 321#, Nanjing, 210008, People's Republic of China.
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Gaba A, Hörath S, Hager M, Marculescu R, Ott J. Basal Anti Mullerian hormone levels and endometrial thickness at midcycle can predict the outcome after clomiphene citrate stimulation in anovulatory women with PCOS, a retrospective study. Arch Gynecol Obstet 2019; 300:1751-1757. [PMID: 31696366 PMCID: PMC6875151 DOI: 10.1007/s00404-019-05359-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 10/25/2019] [Indexed: 01/20/2023]
Abstract
Purpose Recent studies reported that in polycystic ovary syndrome (PCOS) patients, other stimulation agents are superior to the popular first-line regimen, clomiphene citrate (CC) for ovarian stimulation. Nonetheless, CC is still widely used since it is not clear which patients will not respond to it. Furthermore, the prognostic value of endometrium thickness at midcycle is controversial. We aimed to find factors predicting the response to CC and the prognostic value of endometrial thickness at midcycle. Methods We collected data retrospectively from 89 anovulatory PCOS patients who had the first stimulation with 50 mg CC. We analyzed the basal levels of AMH, testosterone, LH, LH:FSH ratio and the endometrial thickness at midcycle by univariate, followed by multivariate regression. The outcome measures were pregnancy, follicle maturation and endometrial thickness at midcycle. Results Stimulation with 50 mg CC resulted in follicle maturation in 50.6% of the women and in 27.0% pregnancies. In the univariate analysis, greater endometrial thickness, lower LH and AMH levels and a lower LH:FSH ratio were associated with pregnancy (p < 0.05). In the multivariate analysis, only endometrial thickness remained predictive (p = 0.045). The endometrial thickness cutoff level of ≥ 8 mm showed a sensitivity of 87.5% (96% CI 67.6–97.3) and a specificity of 66.7% (95% CI 43.0–85.4) for prediction of pregnancy. In the multivariate analysis AMH levels 5.4 (3.4; 7.0) (ng/mL) predicted pregnancy (β = − 0.194 ± 0.092; p = 0.034) Conclusion We suggest to refrain from CC as first-line regimen in patients with AMH > 7 ng/ml. Under CC treatment, the cutoff value of ≥ 8 mm endometrium thickness at midcycle is associated with a better outcome.
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Affiliation(s)
- Aulona Gaba
- Department of Obstetrics and Gynecology, Clinical Division of Obstetrics and Maternal-Fetal Medicine, Medical University of Vienna, Vienna, Austria
| | - Steffen Hörath
- Department of Obstetrics and Gynecology, Clinical Division of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Marlene Hager
- Department of Obstetrics and Gynecology, Clinical Division of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Rodrig Marculescu
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Johannes Ott
- Department of Obstetrics and Gynecology, Clinical Division of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.
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Liu KE, Hartman M, Hartman A. Management of thin endometrium in assisted reproduction: a clinical practice guideline from the Canadian Fertility and Andrology Society. Reprod Biomed Online 2019; 39:49-62. [PMID: 31029557 DOI: 10.1016/j.rbmo.2019.02.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 02/12/2019] [Indexed: 02/03/2023]
Abstract
The impact and management of thin endometrium is a common challenge for patients undergoing assisted reproduction. The objective of this Canadian Fertility and Andrology Society (CFAS) guideline is to provide evidence-based recommendations using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) framework on the assessment, impact and management of thin endometrium in assisted reproduction. The effect of endometrial thickness on pregnancy and live birth outcomes in ovarian stimulation and IVF (fresh and frozen cycles) is addressed. In addition, recommendations on the use of adjuvants to improve endometrial thickness and pregnancy outcomes are provided.
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Affiliation(s)
- Kimberly E Liu
- Mount Sinai Fertility, 250 Dundas St. W, Suite 700, Dept of Obstetrics and Gynecology, Mount Sinai Hospital, 600 University Ave., University of Toronto, Toronto ON, M5T 2Z5, Canada.
| | - Michael Hartman
- Trio Fertility, 655 Bay St., Suite 1101, Toronto ON, M5G 2K4, Canada
| | - Alex Hartman
- True North Imaging, 7330 Yonge St., Suite 120, Thornhill ON, L4J 7Y7, Canada
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Liu Y, Ye XY, Chan C. The association between endometrial thickness and pregnancy outcome in gonadotropin-stimulated intrauterine insemination cycles. Reprod Biol Endocrinol 2019; 17:14. [PMID: 30674305 PMCID: PMC6345006 DOI: 10.1186/s12958-019-0455-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 01/09/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Intrauterine insemination (IUI) is the first-line treatment for non-tubal infertility. Injectable gonadotropins are often chosen as adjunctive stimulation to promote the growth of ovarian follicles in IUI cycles. The growing follicles produce estrogen, which induces endometrial proliferation and increased endometrial stripe thickness (EST). The association between EST and pregnancy outcome in gonadotropin stimulated IUI is not well studied. The objective of this study is to determine if EST can predict pregnancy outcome in gonadotropin-stimulated IUI cycles. METHODS A retrospective review was conducted of all exclusively gonadotropin-stimulated IUI cycles performed between 2012 and 2015 at an academic fertility clinic. Mean endometrial thickness was compared in positive versus negative cycles using Student T-test. Peak EST values were then divided into four groups of < 7 mm, 7.0-10.4 mm, 10.5-13.9 mm, and ≥ 14 mm. Multiple logistic regression analysis adjusted for potential confounders was conducted to assess the impact of peak EST on cycle outcome. RESULTS Our sample consisted of 1065 IUI cycles representing 548 patients with a 16.9% clinical pregnancy rate and 20.5% conception rate. No significant differences in mean peak EST were observed between cycles that achieved clinical pregnancy or conception and those that did not. Division of peak EST into four groups showed a non-linear relationship between peak EST and cycle outcome, with highest rates of positive outcomes between 10.5-13.9 mm. The odds of clinical pregnancy and conception increased by 38 and 44% respectively with each subsequent peak EST category up to 10.5-13.9 mm, following which they declined. CONCLUSION This is the largest study to date evaluating the effect of peak EST on gonadotropin-stimulated IUI cycles exclusively. The lack of significant difference in peak EST between positive and negative outcomes cycles may be due to the non-linear relationship between cycle outcomes and peak EST. Peak EST in the range of 10.5-13.9 mm was associated with significantly higher conception rates and a trend towards higher clinical pregnancy rates. This non-linearity is likely one of the reasons that EST in isolation was found to be a poor predictor of IUI outcomes, and therefore is not appropriate to be used as the sole indicator for cycle cancellation.
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Affiliation(s)
- Yiwen Liu
- 0000 0001 2157 2938grid.17063.33Faculty of Medicine, University of Toronto, 1 King’s College Circle Medical Sciences Building, Room 2109, Toronto, ON M5S 1A8 Canada
- 0000 0001 2157 2938grid.17063.33Department of Obstetrics and Gynaecology, University of Toronto, 123 Edward St. Suite 1200, Toronto, ON M5G 1E2 Canada
| | - Xiang Y. Ye
- 0000 0004 0473 9881grid.416166.2Maternal Infant Care Research Centre, Mount Sinai Hospital , 700 University Ave, Toronto, ON M5G 1X6 Canada
| | - Crystal Chan
- 0000 0001 2157 2938grid.17063.33Department of Obstetrics and Gynaecology, University of Toronto, 123 Edward St. Suite 1200, Toronto, ON M5G 1E2 Canada
- 0000 0004 0473 9881grid.416166.2Mount Sinai Fertility, Mount Sinai Hospital, 250 Dundas St W #700, Toronto, ON M5T 2Z5 Canada
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Cohlen B, Bijkerk A, Van der Poel S, Ombelet W. IUI: review and systematic assessment of the evidence that supports global recommendations. Hum Reprod Update 2018; 24:300-319. [PMID: 29452361 DOI: 10.1093/humupd/dmx041] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 12/19/2017] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND IUI with or without ovarian stimulation (OS) has become a first-line treatment option for many infertile couples, worldwide. The appropriate treatment modality for couples and their clinical management through IUI or IUI/OS cycles must consider maternal and perinatal outcomes, most notably the clinical complication of higher-order multiple pregnancies associated with IUI-OS. With a current global emphasis to continue to decrease maternal and perinatal mortality and morbidity, the World Health Organization (WHO) had established a multi-year project to review the evidence for the establishment of normative guidance for the implementation of IUI as a treatment to address fertility problems, and to consider its cost-effectiveness for lower resource settings. OBJECTIVE AND RATIONALE The objective of this review is to provide a review of the evidence of 13 prioritized questions that cover IUI with and without OS. We provide summary recommendations for the development of global, evidence-based guidelines based upon methodology established by the WHO. SEARCH METHODS We performed a comprehensive search using question-specific relevant search terms in May 2015. For each PICO (Population, Intervention, Comparison and Outcomes) drafted by WHO, specific search terms were used to find the available evidence in MEDLINE (1950 to May 2015) and The Cochrane Library (until May 2015). After presentation to an expert panel, a further hand search of references in relevant reviews was performed up to January 2017. Articles that were found to be relevant were read and analysed by two investigators and critically appraised using the Cochrane Collaboration's tool for assessing risk of bias, and AMSTAR in case of systematic reviews. The quality of the evidence was assessed using the GRADE system. An independent expert review process of our analysis was conducted in November 2016. OUTCOMES This review provides an assessment and synthesis of the evidence that covers 13 clinical questions including the indications for the use of IUI versus expectant management, the sperm parameters required, the best and optimal method of timing and number of inseminations per cycle, prevention strategies to decrease multiple gestational pregnancies, and the cost-effectiveness of IUI versus IVF. We provide an evidence-based formulation of 20 recommendations, as well as two best practice points that address the integration of methods for the prevention of infection in the IUI laboratory. The quality of the evidence ranges from very low to high, with evidence that may be decades old but of high quality, however, we further discuss where critical research gaps in the evidence remain. WIDER IMPLICATIONS This review presents an evidence synthesis assessment and includes recommendations that will assist health care providers worldwide with their decision-making when considering IUI treatments, with or without OS, for their patients presenting with fertility problems.
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Affiliation(s)
- Ben Cohlen
- Isala Fertility Center, Isala, Dr van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Aartjan Bijkerk
- Isala Fertility Center, Isala, Dr van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Sheryl Van der Poel
- WHO/HRP (the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction), Avenue Appia 20, 1202 Geneva, Switzerland
| | - Willem Ombelet
- Genk Institute for Fertility Technology, Department of Obstetrics and Gynaecology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600 Genk, Belgium.,Department of Physiology, Hasselt University, Martelarenlaan 42, 3500 Hasselt, Belgium
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Gutarra‐Vilchez RB, Bonfill Cosp X, Glujovsky D, Viteri‐García A, Runzer‐Colmenares FM, Martinez‐Zapata MJ. Vasodilators for women undergoing fertility treatment. Cochrane Database Syst Rev 2018; 10:CD010001. [PMID: 30312988 PMCID: PMC6517312 DOI: 10.1002/14651858.cd010001.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The rate of successful pregnancies brought to term has barely increased since the first assisted reproductive technology (ART) technique became available. Vasodilators have been proposed to increase endometrial receptivity, thicken the endometrium, and favour uterine relaxation, all of which could improve uterine receptivity and enhance the chances for successful assisted pregnancy. OBJECTIVES To evaluate the effectiveness and safety of vasodilators in women undergoing fertility treatment. SEARCH METHODS We searched the following electronic databases, trial registers, and websites: the Cochrane Gynaecology and Fertility Group (CGF) Specialised Register of controlled trials, the Cochrane Central Register of of Controlled Trials, via the Cochrane Register of Studies Online (CRSO), MEDLINE, Embase, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Knowledge, the Open System for Information on Grey Literature in Europe (OpenSIGLE), the Latin American and Caribbean Health Science Information Database (LILACS), clinical trial registries, and the reference lists of relevant articles. We conducted the search in October 2017 and applied no language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing vasodilators alone or in combination with other treatments versus placebo or no treatment or versus other agents in women undergoing fertility treatment. DATA COLLECTION AND ANALYSIS Four review authors independently selected studies, assessed risk of bias, extracted data, and calculated risk ratios (RRs). We combined study data using a fixed-effect model and assessed evidence quality using Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE) methods. Our primary outcomes were live birth or ongoing pregnancy and vasodilator side effects. Secondary outcomes included clinical pregnancy, endometrial thickness, multiple pregnancy, miscarriage, and ectopic pregnancy. MAIN RESULTS We included 15 studies with a total of 1326 women. All included studies compared a vasodilator versus placebo or no treatment. We judged most of these studies as having unclear risk of bias. Overall, the quality of evidence was low to moderate for most outcomes. The main limitations were imprecision due to low numbers of events and participants and risk of bias due to unclear methods of randomisation.Vasodilators probably make little or no difference in rates of live birth compared with placebo or no treatment (RR 1.18, 95% confidence interval (CI) 0.83 to 1.69; three RCTs; N = 350; I² = 0%; moderate-quality evidence) but probably increase overall rates of side effects including headache and tachycardia (RR 2.35, 95% CI 1.51 to 3.66; four RCTs; N = 418; I² = 0%; moderate-quality evidence). Evidence suggests that if 236 per 1000 women achieve live birth with placebo or no treatment, then between 196 and 398 per 1000 will do so with the use of vasodilators.Compared with placebo or no treatment, vasodilators may slightly improve clinical pregnancy rates (RR 1.45, 95% CI 1.19 to 1.77; 11 RCTs; N = 1054; I² = 6%; low-quality evidence). Vasodilators probably make little or no difference in rates of multiple gestation (RR 1.15, 95% CI 0.55 to 2.42; three RCTs; N = 370; I² = 0%; low-quality evidence), miscarriage (RR 0.83, 95% CI 0.37 to 1.86; three RCTs; N = 350; I² = 0%; low-quality evidence), or ectopic pregnancy (RR 1.48, 95% CI 0.25 to 8.69; two RCTs; N = 250; I² = 5%; low-quality evidence). All studies found benefit for endometrial thickening, but reported effects varied (I² = 92%) and ranged from a mean difference of 0.80 higher (95% CI 0.18 to 1.42) to 3.57 higher (95% CI 3.01 to 4.13) with very low-quality evidence, so we are uncertain how to interpret these results. AUTHORS' CONCLUSIONS Evidence was insufficient to show whether vasodilators increase the live birth rate in women undergoing fertility treatment. However, low-quality evidence suggests that vasodilators may slightly increase clinical pregnancy rates. Moderate-quality evidence shows that vasodilators increase overall side effects in comparison with placebo or no treatment. Adequately powered studies are needed so that each treatment can be evaluated more accurately.
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Affiliation(s)
- Rosa B Gutarra‐Vilchez
- San Martin de Porres UniversityFaculty of Human MedicineAlameda del Corregidor N°1531, Urb. Los Sirius, Etapa III, La MolinaLimaPeru
| | - Xavier Bonfill Cosp
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 167Pavilion 18BarcelonaCatalunyaSpain08025
| | - Demián Glujovsky
- CEGYR (Centro de Estudios en Genética y Reproducción)Reproductive MedicineViamonte 1432,Buenos AiresArgentina
| | - Andres Viteri‐García
- Universidad Tecnológica EquinoccialCochrane Ecuador. Centro de Investigación en Salud Pública y Epidemiología Clínica (CISPEC). Facultad de Ciencias de la Salud Eugenio EspejoAvenida Mariana de Jesús y OccidentalQuitoPichinchaEcuador170527
| | - Fernando M. Runzer‐Colmenares
- Faculty of Medicine, Universidad de San Martín de PorresResearch InstituteAlameda del Corregidor Ave. 1531, Urb. Los Sirius, Las Viñas, La MolinaLimaLimaPeru12
| | - Maria José Martinez‐Zapata
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 167Pavilion 18BarcelonaCatalunyaSpain08025
- Equinoccial Technological UniversityCochrane Ecuador. Center for Research in Public Health and Clinical Epidemiology (CISPEC). Eugenio Espejo School of Health SciencesAvenida República de El Salvador 733 y Portugal Edificio Gabriela 3. Of. 403 Casilla Postal 17‐17‐525QuitoEcuador
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46
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Tanbo T, Mellembakken J, Bjercke S, Ring E, Åbyholm T, Fedorcsak P. Ovulation induction in polycystic ovary syndrome. Acta Obstet Gynecol Scand 2018; 97:1162-1167. [PMID: 29889977 DOI: 10.1111/aogs.13395] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 06/05/2018] [Indexed: 02/03/2023]
Abstract
The objective of this narrative review was to suggest a rational order of treatment choices in anovulatory women with polycystic ovary syndrome (PCOS), for whom a multitude of treatment options exist. In obese/overweight women with PCOS the importance of weight reduction should be stressed. Inositol, a dietary supplement with a documented effect on ovulation and without adverse effects in the doses recommended, may be suggested. Additional first-line medical alternatives include insulin sensitizers, selective estrogen receptor modulators, and aromatase inhibitors. Of these, the aromatase inhibitor letrozole and the combination of clomiphene citrate and metformin have the highest rates of ovulation and live birth. Second-line treatments are ovarian electrocautery and low-dose follicle-stimulating hormone stimulation. Controlled ovarian stimulation with in vitro fertilization, should be considered the last option as it carries a significant risk of ovarian hyperstimulation syndrome in patients with PCOS.
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Affiliation(s)
- Tom Tanbo
- Department of Reproductive Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jan Mellembakken
- Department of Reproductive Medicine, Oslo University Hospital, Oslo, Norway
| | - Sverre Bjercke
- Department of Reproductive Medicine, Oslo University Hospital, Oslo, Norway
| | - Eva Ring
- Department of Reproductive Medicine, Oslo University Hospital, Oslo, Norway
| | - Thomas Åbyholm
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Peter Fedorcsak
- Department of Reproductive Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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von Wolff M, Stute P, Mosimann B. Neues und praktisch Relevantes aus der gynäkologischen Endokrinologie, Reproduktionsmedizin und Pränatalmedizin: Teil 1. GYNAKOLOGISCHE ENDOKRINOLOGIE 2018. [DOI: 10.1007/s10304-018-0177-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Satwik R, Kochhar M. Effect of simultaneously started clomiphene citrate and gonadotropins in antagonist regimes, on cumulative live births, fresh-cycle live births and cost of stimulation in IVF cycles. J Obstet Gynaecol Res 2018; 44:1107-1117. [PMID: 29644764 DOI: 10.1111/jog.13624] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 02/02/2018] [Indexed: 12/28/2022]
Abstract
AIM The aim of the study was to compare simultaneously started clomiphene citrate (CC) and gonadotropins (Gn) with gonadotropins alone in conventional antagonist regimes with respect to fresh-cycle live births, cumulative live births and cost of ovarian stimulation per started cycle. METHODS This was a single-center prospective cohort study conducted over 1 year. Women undergoing autologous in vitro fertilization (IVF) treatment in antagonist protocols and who consented to participate in the study were divided into two cohorts. The CC cohort (n = 86) received 50 mg CC for 5 days and individualized Gn daily until the hCG trigger, both starting from day 2 and antagonist daily from day 8 of menstrual cycle. The Gn-only cohort (n = 349) received individualized Gn from day 2 and the antagonist from day 7 of menstrual cycle. IVF outcomes and cost of stimulation were compared between two cohorts across expected ovarian response categories. RESULTS The CC cohort used a mean lower dose of Gn (1741.38 ± 604.46 vs 1980.54 ± 686.42; MD = -239.16; 95%CI = -348.03 to -189.24; P = 0.003) over fewer days (8.54 ± 1.86 vs 9.25 ± 1.97; MD =-0.71;95% CI = -1.17 to -0.25; P = 0.0026) to achieve similar retrieved oocytes, (9.19 ± 5.92 vs 9.36 ± 6.96; MD = -0.17; 95%CI -1.77 to + 1.43; P = 0.83), positive bhCG rates (40% vs 29.6%, MD = 10.4%; OR = 1.65, 95%CI = 0.95-2.86; P = 0.078) and live births in fresh cycles (32.31% vs 21.30%; MD = 11.01%; OR = 1.76; 95%CI = 0.97-3.19; P = 0.06) and cumulative live births per initiated cycle (30.23% vs 20.34%; MD = 9.89%; OR = 1.697; 95%CI = 0.99-2.88; P = 0.0501). The dose lowering achieved a 28-40% reduction in the cost of stimulation, which was most noticeable in the hyper-responder category for both hMG cycles, (Rs.11 602.3 ± 3365.9 vs 19615 ± 2677.1; MD = -8012.7; %age reduction: 40.8%; P = 0.0007) and recombinant FSH cycles (Rs. 22 459.6 ± 6255.3 vs 33 022.1 ± 9891.2; MD: -10 562; %age reduction: -32%; P = 0.0001). CONCLUSION CC started simultaneously with Gn in antagonist regimes helps lower the cost of stimulation without affecting IVF outcomes.
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Affiliation(s)
- Ruma Satwik
- Centre of IVF and Human Reproduction, Institute of Obstetrics and Gynaecology, Sir Gangaram Hospital, New Delhi, India
| | - Mohinder Kochhar
- Centre of IVF and Human Reproduction, Institute of Obstetrics and Gynaecology, Sir Gangaram Hospital, New Delhi, India
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Weiss NS, Nahuis MJ, Bordewijk E, Oosterhuis JE, Smeenk JM, Hoek A, Broekmans FJ, Fleischer K, de Bruin JP, Kaaijk EM, Laven JS, Hendriks DJ, Gerards MH, van Rooij IA, Bourdrez P, Gianotten J, Koks C, Lambalk CB, Hompes PG, van der Veen F, Mol BWJ, van Wely M. Gonadotrophins versus clomifene citrate with or without intrauterine insemination in women with normogonadotropic anovulation and clomifene failure (M-OVIN): a randomised, two-by-two factorial trial. Lancet 2018; 391:758-765. [PMID: 29273245 DOI: 10.1016/s0140-6736(17)33308-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 11/29/2017] [Accepted: 11/30/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND In many countries, clomifene citrate is the treatment of first choice in women with normogonadotropic anovulation (ie, absent or irregular ovulation). If these women ovulate but do not conceive after several cycles with clomifene citrate, medication is usually switched to gonadotrophins, with or without intrauterine insemination. We aimed to assess whether switching to gonadotrophins is more effective than continuing clomifene citrate, and whether intrauterine insemination is more effective than intercourse. METHODS In this two-by-two factorial multicentre randomised clinical trial, we recruited women aged 18 years and older with normogonadotropic anovulation not pregnant after six ovulatory cycles of clomifene citrate (maximum of 150 mg daily for 5 days) from 48 Dutch hospitals. Women were randomly assigned using a central password-protected internet-based randomisation programme to receive six cycles with gonadotrophins plus intrauterine insemination, six cycles with gonadotrophins plus intercourse, six cycles with clomifene citrate plus intrauterine insemination, or six cycles with clomifene citrate plus intercourse. Clomifene citrate dosages varied from 50 to 150 mg daily orally and gonadotrophin starting dose was 50 or 75 IU daily subcutaneously. The primary outcome was conception leading to livebirth within 8 months after randomisation defined as any baby born alive after a gestational age beyond 24 weeks. Primary analysis was by intention to treat. We made two comparisons, one in which gonadotrophins were compared with clomifene citrate and one in which intrauterine insemination was compared with intercourse. This completed study is registered with the Netherlands Trial Register, number NTR1449. FINDINGS Between Dec 8, 2008, and Dec 16, 2015, we randomly assigned 666 women to gonadotrophins and intrauterine insemination (n=166), gonadotrophins and intercourse (n=165), clomifene citrate and intrauterine insemination (n=163), or clomifene citrate and intercourse (n=172). Women allocated to gonadotrophins had more livebirths than those allocated to clomifene citrate (167 [52%] of 327 women vs 138 [41%] of 334 women, relative risk [RR] 1·24 [95% CI 1·05-1·46]; p=0·0124). Addition of intrauterine insemination did not increase livebirths compared with intercourse (161 [49%] vs 144 [43%], RR 1·14 [95% CI 0·97-1·35]; p=0·1152). Multiple pregnancy rates for the two comparisons were low and not different. There were three adverse events: one child with congenital abnormalities and one stillbirth in two women treated with clomifene citrate, and one immature delivery due to cervical insufficiency in a woman treated with gonadotrophins. INTERPRETATION In women with normogonadotropic anovulation and clomifene citrate failure, a switch of treatment to gonadotrophins increased the chance of livebirth over treatment with clomifene citrate; there was no evidence that addition of intrauterine insemination does so. FUNDING The Netherlands Organization for Health Research and Development.
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Affiliation(s)
- Nienke S Weiss
- Center for Reproductive Medicine, Academic Medical Center, Amsterdam, Netherlands; Center for Reproductive Medicine, VU University Medical Center, Amsterdam, Netherlands
| | - Marleen J Nahuis
- Center for Reproductive Medicine, VU University Medical Center, Amsterdam, Netherlands
| | - Esmee Bordewijk
- Center for Reproductive Medicine, VU University Medical Center, Amsterdam, Netherlands
| | - Jurjen E Oosterhuis
- Department of Obstetrics and Gynecology, St Antonius Ziekenhuis, Utrecht, Netherlands
| | - Jesper Mj Smeenk
- Department of Obstetrics and Gynecology, Elisabeth Ziekenhuis, Tilburg, Netherlands
| | - Annemieke Hoek
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Frank Jm Broekmans
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands
| | - Kathrin Fleischer
- Department of Obstetrics and Gynaecology, Radboud University, Nijmegen, Netherlands
| | - Jan Peter de Bruin
- Jeroen Bosch Hospital, Department of Obstetrics and Gynecology, 's Hertogenbosch, Netherlands
| | - Eugenie M Kaaijk
- Department of Obstetrics and Gynecology, OLVG Amsterdam-Oost, Netherlands
| | - Joop Se Laven
- Department of Obstetrics and Gynecology, Erasmus MC Rotterdam, Rotterdam, Netherlands
| | - Dave J Hendriks
- Department of Obstetrics and Gynecology, Amphia Ziekenhuis Breda, Breda, Netherlands
| | - Marie H Gerards
- Department of Obstetrics and Gynecology, Martini Hospital Groningen, Groningen, Netherlands
| | - Ilse Aj van Rooij
- Department of Obstetrics and Gynecology, Elisabeth-Tweesteden Hospital, Tweesteden, Netherlands
| | - Petra Bourdrez
- Department of Obstetrics and Gynecology, VieCuri Medical Center, Venlo, Netherlands
| | - Judith Gianotten
- Department of Obstetrics and Gynecology, Spaarne Gasthuis, Haarlem, Netherlands
| | - Carolien Koks
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, Netherlands
| | - Cornelis B Lambalk
- Center for Reproductive Medicine, VU University Medical Center, Amsterdam, Netherlands
| | - Peter G Hompes
- Center for Reproductive Medicine, VU University Medical Center, Amsterdam, Netherlands
| | - Fulco van der Veen
- Center for Reproductive Medicine, Academic Medical Center, Amsterdam, Netherlands
| | - Ben Willem J Mol
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia; Academic Medical Center, Amsterdam, Netherlands
| | - Madelon van Wely
- Center for Reproductive Medicine, Academic Medical Center, Amsterdam, Netherlands.
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陈 彩, 颜 秋, 周 秀, 冼 英, 郭 晓, 全 松. [Effects of raloxifene at two different doses for ovulation induction on endometrial pinopodes in mice during the implantation window]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2018; 38:234-238. [PMID: 29502066 PMCID: PMC6743885 DOI: 10.3969/j.issn.1673-4254.2018.02.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To compare the expression of pinopodes, the marker of endometrial receptivity, during the implantation window in Kunming mice stimulated with two different doses of raloxifene (RAL). METHODS Forty-eight 8-week-old female Kunming mice were randomly divided into 4 groups (n=12), namely saline group, clomiphene citrate (CC, 18 mg/kg) group, RAL (33 mg/kg) group and RAL (44 mg/kg group). In each group, the mice received intragastric administration of 1 mL of normal saline containing CC or RAL at the specified doses or saline only as indicated for ovulation induction, once daily for 2 days. The mice received then injection with 5 IU human chorionic gonadotropin (HCG) and mated and on day 4.5 of gestation, the pregnant mice were sacrificed for examination of the uterus with scanning electron microscopy. RESULTS Abundant and well developed pinopodes were observed in the endometrium of the mice in the 2 RAL groups and in the saline control group. The mice in CC group showed obviously reduced endometrial pinopodes with poor development. CONCLUSIONS RAL at two different doses does not obviously affect the expression of pinopodes in the uterine epithelium of mice, suggesting the safety of RAL at these two doses for ovulation induction without causing adverse effects on endometrial receptivity.
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Affiliation(s)
- 彩蓉 陈
- 广州医科大学附属第六医院//清远市人民医院生殖中心,广东 清远 511518Reproductive Medicine Center, Sixth Affiliated Hospital of Guangzhou Medical University/Qingyuan People's Hospital, Qingyuan 511518, China
| | - 秋霞 颜
- 广州医科大学附属第六医院//清远市人民医院生殖中心,广东 清远 511518Reproductive Medicine Center, Sixth Affiliated Hospital of Guangzhou Medical University/Qingyuan People's Hospital, Qingyuan 511518, China
| | - 秀琴 周
- 广州医科大学附属第六医院//清远市人民医院生殖中心,广东 清远 511518Reproductive Medicine Center, Sixth Affiliated Hospital of Guangzhou Medical University/Qingyuan People's Hospital, Qingyuan 511518, China
| | - 英杰 冼
- 广州医科大学附属第六医院//清远市人民医院生殖中心,广东 清远 511518Reproductive Medicine Center, Sixth Affiliated Hospital of Guangzhou Medical University/Qingyuan People's Hospital, Qingyuan 511518, China
| | - 晓燕 郭
- 广州医科大学附属第六医院//清远市人民医院生殖中心,广东 清远 511518Reproductive Medicine Center, Sixth Affiliated Hospital of Guangzhou Medical University/Qingyuan People's Hospital, Qingyuan 511518, China
| | - 松 全
- 南方医科大学附属南方医院生殖中心,广东 广州 510515Reproductive Medicine Center, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
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