Pregnancy confirmed after controlled ovarian stimulation for infertility: A case report

Undetected, natural conception pregnancies in luteal phase stimulations-case series and review of literature

STUDY QUESTION

What is the risk of an undetected natural conception pregnancy during luteal phase ovarian stimulation, and how does it impact the pregnancy's course?

SUMMARY ANSWER

The risk for an undetected, natural conception pregnancy in luteal phase ovarian stimulation is low and it appears that ovarian stimulation is unlikely to harm the pregnancy.

WHAT IS KNOWN ALREADY

Random start ovarian stimulation appears to be similarly effective as early follicular stimulation start; and it allows ovarian stimulation to be started independent of the cycle day and throughout the cycle, in accordance with the patients' and clinics' schedule as long as there is no intention of a fresh embryo transfer in the same cycle. Starting ovarian stimulation in the luteal phase bears the possibility of an-at the timepoint of stimulation start-undetected, natural conception pregnancy that has already occurred. There is scarce data on the incidence of this event as well as on the possible implications of ovarian stimulation on the course of an existing pregnancy.

STUDY DESIGN, SIZE, DURATION

This retrospective observational study, performed between June 2017 and January 2024, analyzed luteal phase stimulations, in which a natural conception pregnancy was detected during the ovarian stimulation treatment for IVF/ICSI. Luteal phase stimulation was defined as ovarian stimulation started after ovulation and before the next expected menstrual bleeding, with a serum progesterone (P4) level of >1.5 ng/ml on the day of stimulation start or 1 day before.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women who underwent a luteal phase ovarian stimulation in a tertiary referral ART center.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 488 luteal phase stimulation cycles were included in the analysis. Luteal phase stimulation was only started after a negative serum hCG measurement on the day or 1 day before commencement of ovarian stimulation. Ten patients (2.1%) had an undetected natural conception pregnancy at the time of luteal phase stimulation start. Eight of these patients underwent an ovarian stimulation in a GnRH-antagonist protocol and two in a progestin-primed stimulation protocol (PPOS). Recombinant FSH was used as stimulation medication for all patients, the patients with a PPOS protocol received additional recombinant LH. One pregnancy (0.2%) was detected after the oocyte retrieval, the other nine pregnancies were detected either due to persistent high serum progesterone levels or due to an increasing progesterone level after an initial decrease before oocyte retrieval. In the cycles with an undetected natural conception pregnancy, the median number of stimulation days was 8 days (range: 6-11 days) and median serum hCG at detection of pregnancy was 59 IU hCG (range: 14.91-183.1). From 10 patients with a pregnancy, three patients delivered a healthy baby, two patients had ongoing pregnancies at the time of summarizing the data, three patients had biochemical pregnancies (patient age: 30, 39, and 42 years), one patient had an ectopic pregnancy which required a salpingectomy, and one patient (age: 34 years) had an early pregnancy loss.

LIMITATIONS, REASONS FOR CAUTION

The retrospective study design and the small sample size can limit the accuracy of the estimates.

WIDER IMPLICATIONS OF THE FINDINGS

Overall, there is a small risk of undetected natural conception pregnancies when luteal phase stimulation is undertaken. It appears that there are no adverse effects through either direct effect on the embryo or indirectly through a detrimental effect on the corpus luteum function on the pregnancy in our cohort.

STUDY FUNDING/COMPETING INTEREST(S)

This study did not receive funding. The authors declare that there is no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Clomiphene citrate mild stimulation improved follicular development outcomes in PCOS women with high luteinizing hormone and poor ovarian response: A case report

INTRODUCTION

Polycystic ovary syndrome (PCOS) is a main cause of anovulatory infertility in women of reproductive age. About 30% to 50% of patients with PCOS has high serum basal luteinizing hormone (LH) levels, and almost 5% of PCOS women with high LH have poor ovarian response (POR). We reported a case of a PCOS woman with high basal LH levels who canceled due to POR during two consecutive controlled ovarian stimulation treatments, which was considered to be related to the suppression of LH levels during downregulation. Clomiphene citrate (CC) combined with human menopausal urinary gonadotropin (HMG) mild regimen did not affect LH levels and obtained good follicular development, providing a new treatment insight for patients with PCOS combined with POR.

PATIENT CONCERNS

A 28-year-old PCOS woman with high basal LH levels, underwent IVF assisted pregnancy treatment in our hospital, whom canceled due to POR during two traditional controlled ovulation induction program. Follicular development was finally achieved with CC milder protocol.

DIAGNOSIS

This patient with the diagnosis of PCOS was undergone IVF assisted pregnancy treatment in our hospital.

INTERVENTIONS

CC protocol supports the development of follicular.

OUTCOMES

CC protocol resulted in better follicular development and high-quality embryos due to the continuous maintenance of an elevated LH levels.

CONCLUSION

PCOS women with poor ovarian response required relatively higher LH to maintain the normal development of follicles.