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Kastora SL, Gkova G, Stavridis K, Balachandren N, Kastoras A, Karakatsanis A, Mavrelos D. Comparison of luteal support protocols in fresh IVF/ICSI cycles: a network meta-analysis. Sci Rep 2024; 14:14492. [PMID: 38914570 PMCID: PMC11196689 DOI: 10.1038/s41598-024-64804-z] [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: 09/25/2023] [Accepted: 06/13/2024] [Indexed: 06/26/2024] Open
Abstract
Despite the proven superiority of various luteal phase support protocols (LPS) over placebo in view of improved pregnancy rates in fresh cycles of IVF (in vitro fertilization) and ICSI (intracytoplasmic sperm injection) cycles, there is ongoing controversy over specific LPS protocol selection, dosage, and duration. The aim of the present study was to identify the optimal LPS under six core aspects of ART success, clinical pregnancy, live birth as primary outcomes and biochemical pregnancy, miscarriage, multiple pregnancy, ovarian hyperstimulation syndrome (OHSS) events as secondary outcomes. Twelve databases, namely Embase (OVID), MEDLINE (R) (OVID), GlobalHealth (Archive), GlobalHealth, Health and Psychosocial Instruments, Maternity & Infant Care Database (MIDIRS), APA PsycTests, ClinicalTrials.gov, HMIC Health Management Information Consortium, CENTRAL, Web of Science, Scopus and two prospective registers, MedRxiv, Research Square were searched from inception to Aug.1st, 2023, (PROSPERO Registration: CRD42022358986). Only Randomised Controlled Trials (RCTs) were included. Bayesian network meta-analysis (NMA) model was employed for outcome analysis, presenting fixed effects, odds ratios (ORs) with 95% credibility intervals (CrIs). Vaginal Progesterone (VP) was considered the reference LPS given its' clinical relevance. Seventy-six RCTs, comparing 22 interventions, and including 26,536 participants were included in the present NMA. Overall CiNeMa risk of bias was deemed moderate, and network inconsistency per outcome was deemed low (Multiple pregnancy χ2: 0.11, OHSS χ2: 0.26), moderate (Clinical Pregnancy: χ2: 7.02, Live birth χ2: 10.95, Biochemical pregnancy: χ2: 6.60, Miscarriage: χ2: 11.305). Combinatorial regimens, with subcutaneous GnRH-a (SCGnRH-a) on a vaginal progesterone base and oral oestrogen (OE) appeared to overall improve clinical pregnancy events; VP + OE + SCGnRH-a [OR 1.57 (95% CrI 1.11 to 2.22)], VP + SCGnRH-a [OR 1.28 (95% CrI 1.05 to 1.55)] as well as live pregnancy events, VP + OE + SCGnRH-a [OR 8.81 (95% CrI 2.35 to 39.1)], VP + SCGnRH-a [OR 1.76 (95% CrI 1.45 to 2.15)]. Equally, the progesterone free LPS, intramuscular human chorionic gonadotrophin, [OR 9.67 (95% CrI 2.34, 73.2)] was also found to increase live birth events, however was also associated with an increased probability of ovarian hyperstimulation, [OR 1.64 (95% CrI 0.75, 3.71)]. The combination of intramuscular and vaginal progesterone was associated with higher multiple pregnancy events, [OR 7.09 (95% CrI 2.49, 31.)]. Of all LPS protocols, VP + SC GnRH-a was found to significantly reduce miscarriage events, OR 0.54 (95% CrI 0.37 to 0.80). Subgroup analysis according to ovarian stimulation (OS) protocol revealed that the optimal LPS across both long and short OS, taking into account increase in live birth and reduction in miscarriage as well as OHSS events, was VP + SCGnRH-a, with an OR 2.89 [95% CrI 1.08, 2.96] and OR 2.84 [95% CrI 1.35, 6.26] respectively. Overall, NMA data suggest that combinatorial treatments, with the addition of SCGnRH-a on a VP base result in improved clinical pregnancy and live birth events in both GnRH-agonist and antagonist ovarian stimulation protocols.
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Affiliation(s)
- Stavroula L Kastora
- UCL EGA Institute for Women's Health, University College London, Medical School Building, Room G15, 86-96 Chenies Mews, 74 Huntley Street, London, WC1E 6HX, UK.
- Department of Obstetrics and Gynaecology, Barnet Hospital, Royal Free London NHS Foundation Trust, London, UK.
| | - Grigoria Gkova
- Department of Obstetrics and Gynaecology, Barnet Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Konstantinos Stavridis
- 2nd Department of Obstetrics and Gynaecology, "Aretaieion" University Hospital, Athens, Greece
| | - Neerujah Balachandren
- UCL EGA Institute for Women's Health, University College London, Medical School Building, Room G15, 86-96 Chenies Mews, 74 Huntley Street, London, WC1E 6HX, UK
| | - Athanasios Kastoras
- Reproductive Medicine Unit, "Leto" Maternity Hospital, Mouson Str. 7-13, 11524, Athens, Greece
| | - Andreas Karakatsanis
- Department of Surgical Sciences, Faculty of Medicine, Uppsala University, Uppsala, Sweden
- Section for Breast Surgery, Department of Surgery, Uppsala University Hospital (Akademiska), Uppsala, Sweden
| | - Dimitrios Mavrelos
- UCL EGA Institute for Women's Health, University College London, Medical School Building, Room G15, 86-96 Chenies Mews, 74 Huntley Street, London, WC1E 6HX, UK
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Chen K, Zhang C, Chen L, Zhao Y, Li H. Reproductive outcomes of dual trigger therapy with GnRH agonist and hCG versus hCG trigger in women with diminished ovarian reserve: a retrospective study. Reprod Biol Endocrinol 2024; 22:35. [PMID: 38566172 PMCID: PMC10985881 DOI: 10.1186/s12958-024-01211-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 03/24/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Diminished ovarian reserve (DOR) is one of the obstacles affecting the reproductive outcomes of patients receiving assisted reproductive therapy. The purpose of this study was to investigate whether dual trigger, including gonadotropin-releasing hormone agonist (GnRHa) and human chorionic gonadotropin (hCG), can improve pregnancy outcomes in patients with DOR undergoing in vitro fertilization (IVF) cycles using mild stimulation protocols. METHODS A total of 734 patients with DOR were included in this retrospective study. Patients were divided into a recombinant hCG trigger group and a dual trigger group (hCG combined with GnRHa) according to the different trigger drugs used. The main outcome measures included the number of oocytes retrieved, the fertilization rate, the number of transferable embryos, the implantation rate, the clinical pregnancy rate, the miscarriage rate, the live birth rate (LBR), and the cumulative live birth rate (CLBR). Generalized linear model and logistic regression analyses were performed for confounding factors. RESULTS There were 337 cycles with a single hCG trigger and 397 cycles with dual trigger. The dual trigger group demonstrated significantly higher numbers of retrieved oocytes [3.60 vs. 2.39, adjusted β = 0.538 (0.221-0.855)], fertilized oocytes [2.55 vs. 1.94, adjusted β = 0.277 (0.031-0.523)] and transferable embryos [1.22 vs. 0.95, adjusted β = 0.162 (-0.005-0.329)] than did the hCG trigger group, whereas no significant difference in the fertilization rate was observed between the two groups. Moreover, the embryo transfer cancellation rate (35.5% vs. 43.9%) was obviously lower in the dual trigger group. Among the fresh embryo transfer cycles, the implantation rate, clinical pregnancy rate, miscarriage rate and live birth rate were similar between the two groups. After controlling for potential confounding variables, the trigger method was identified as an independent factor affecting the number of oocytes retrieved but had no significant impact on the CLBR. CONCLUSIONS Dual triggering of final oocyte maturation with hCG combined with GnRHa can significantly increase the number of oocytes retrieved in patients with DOR but has no improvement effect on the implantation rate, clinical pregnancy rate or LBR of fresh cycles or on the CLBR.
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Affiliation(s)
- Kai Chen
- State Key Laboratory of Female Fertility Promotion, Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, HaiDian District, No. 49 HuaYuan North Road, Beijing, 100191, China
- Key Laboratory of Assisted Reproduction, Ministry of Education, Beijing, 100191, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, 100191, China
- National Clinical Key Specialty Construction Program, P. R. China (2023), Beijing, China
| | - Chunmei Zhang
- State Key Laboratory of Female Fertility Promotion, Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, HaiDian District, No. 49 HuaYuan North Road, Beijing, 100191, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, 100191, China
- National Clinical Key Specialty Construction Program, P. R. China (2023), Beijing, China
| | - Lixue Chen
- State Key Laboratory of Female Fertility Promotion, Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, HaiDian District, No. 49 HuaYuan North Road, Beijing, 100191, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, 100191, China
- National Clinical Key Specialty Construction Program, P. R. China (2023), Beijing, China
| | - Yue Zhao
- State Key Laboratory of Female Fertility Promotion, Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, HaiDian District, No. 49 HuaYuan North Road, Beijing, 100191, China.
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, 100191, China.
- Key Laboratory of Assisted Reproduction, Ministry of Education, Beijing, 100191, China.
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, 100191, China.
- Research Units of Comprehensive Diagnosis and Treatment of Oocyte Maturation Arrest, Chinese Academy of Medical Sciences, Beijing, 100191, China.
- National Clinical Key Specialty Construction Program, P. R. China (2023), Beijing, China.
| | - Hongzhen Li
- State Key Laboratory of Female Fertility Promotion, Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, HaiDian District, No. 49 HuaYuan North Road, Beijing, 100191, China.
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, 100191, China.
- Key Laboratory of Assisted Reproduction, Ministry of Education, Beijing, 100191, China.
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, 100191, China.
- National Clinical Key Specialty Construction Program, P. R. China (2023), Beijing, China.
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Buhbut E, Nabulsi R, Avigdor G, Ben-Ami I. Comparison of pregnancy rates in antagonist cycles after luteal support with GnRH-agonist versus progesterone: prospective randomized study. Arch Gynecol Obstet 2023; 308:255-263. [PMID: 37186265 DOI: 10.1007/s00404-023-07017-5] [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: 12/22/2022] [Accepted: 03/20/2023] [Indexed: 05/17/2023]
Abstract
PURPOSE To compare pregnancy rates in GnRH-antagonist cycles triggered with hCG after luteal phase support with intranasal GnRH-agonist as sole luteal phase support versus standard vaginal progesterone preparation. METHODS Prospective randomized controlled study of patients who underwent antagonist-based IVF cycles triggered with hCG at university-affiliated tertiary medical center between 2020 and 2022. Patients meeting the inclusion criteria were randomly assigned to either intranasal GnRH-agonist or vaginal progesterone for luteal phase support. Pregnancy rates were the main outcome compared between the two study groups. RESULTS A total of 150 patients underwent 164 cycles, 127 cycles of which were included in the study cohort. Of them, 64 (50.4%) and 63 (49.6%) cycles were treated with GnRH-agonist or progesterone, respectively, as sole luteal phase support. A significantly higher pregnancy rate was demonstrated in the GnRH-agonist group compared with the progesterone group. After adjustment of several potential confounders such as age, body mass index, past obstetric history, number of IVF cycles, oocyte retrieved and embryos transferred, GnRH-agonist was still associated with a higher pregnancy rate (odds ratio 3.4, 95% confidence interval 1.4-8.3). Ovarian hyperstimulation syndrome rates were similar between the groups. CONCLUSIONS This prospective study suggests that nasal GnRH-agonist for luteal phase support is associated with higher pregnancy rates compared with standard progesterone support in an antagonist-based protocol triggered with hCG, while maintaining a similar safety profile. TRIAL REGISTRATION Clinicaltrials.gov NCT05484193. Date of registration: August 02 2022. The trial was retrospectively registered.
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Affiliation(s)
- Eadit Buhbut
- IVF and Infertility Unit, Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem, affiliated with the Faculty of Medicine, Hebrew University of Jerusalem, Shmu'el Bait St 12, 9103102, Jerusalem, Israel.
| | - Rinad Nabulsi
- IVF and Infertility Unit, Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem, affiliated with the Faculty of Medicine, Hebrew University of Jerusalem, Shmu'el Bait St 12, 9103102, Jerusalem, Israel
| | - Gilad Avigdor
- IVF and Infertility Unit, Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem, affiliated with the Faculty of Medicine, Hebrew University of Jerusalem, Shmu'el Bait St 12, 9103102, Jerusalem, Israel
| | - Ido Ben-Ami
- IVF and Infertility Unit, Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem, affiliated with the Faculty of Medicine, Hebrew University of Jerusalem, Shmu'el Bait St 12, 9103102, Jerusalem, Israel
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Chang WS, Lin PH, Li CJ, Chern CU, Chen YC, Lin LT, Tsui KH. Additional single dose GnRH agonist during luteal phase support may improve live birth rate in GnRHa-HRT frozen-thawed embryo transfer cycle: a retrospective cohort study. BMC Pregnancy Childbirth 2023; 23:174. [PMID: 36918869 PMCID: PMC10012576 DOI: 10.1186/s12884-023-05491-y] [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: 01/16/2023] [Accepted: 03/02/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND GnRH agonist (GnRHa) has been reported to have direct effects and functional roles in the endometrium and embryos. Several meta-analyses have shown that GnRHa administration in the luteal phase improved the live birth rate or pregnancy rate in both fresh and frozen embryo transfer (FET) cycles. The aim of this study was to investigate whether luteal GnRHa administration could also improve in vitro fertilization (IVF) outcomes in patients undergoing hormone replacement therapy (HRT) cycles with GnRHa suppression. METHODS The retrospective cohort study included a total of 350 patients undergoing GnRHa-HRT FET cycles. The study group included 179 patients receiving an additional single dose of GnRHa in the luteal phase following embryo transfer. A total of 171 patients in the control group did not receive luteal GnRHa. The baseline and cycle characteristics and reproductive outcomes were compared between the two groups. RESULTS Baseline and cycle characteristics were similar between the two groups, except lower AMH levels were found in the luteal GnRHa group than in the control group. The luteal GnRHa group had a significantly higher ongoing pregnancy rate and live birth rate than the control group. The multivariate analysis revealed that luteal GnRHa administration was positively associated with ongoing pregnancy (OR 2.04, 95% CI 1.20-3.47, P = 0.008) and live birth (OR 2.03, 95% CI 1.20-3.45, P = 0.009). When the subgroup of patients with recurrent implantation failure was analyzed, the multivariate analysis also showed that luteal GnRHa administration had beneficial effects on ongoing pregnancy (OR 4.55, 95% CI 1.69-12.30, P = 0.003) and live birth (OR 4.30, 95% CI 1.59-11.65, P = 0.004). CONCLUSIONS Our data suggest that the addition of one luteal dose of GnRHa may improve the live birth rate in patients undergoing the GnRHa-HRT protocol.
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Affiliation(s)
- Wei-Shan Chang
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, No.386, Dazhong 1st Rd., Zuoying Dist, Kaohsiung City, 81362, Taiwan.,Department of Obstetrics and Gynecology, Kaohsiung Armed Forces General Hospital, Kaohsiung City, Taiwan
| | - Pei-Hsuan Lin
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, No.386, Dazhong 1st Rd., Zuoying Dist, Kaohsiung City, 81362, Taiwan
| | - Chia-Jung Li
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, No.386, Dazhong 1st Rd., Zuoying Dist, Kaohsiung City, 81362, Taiwan.,Institute of Biopharmaceutical Sciences, National Sun Yat-sen University, Kaohsiung City, Taiwan
| | - Chyi-Uei Chern
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, No.386, Dazhong 1st Rd., Zuoying Dist, Kaohsiung City, 81362, Taiwan
| | - Yu-Chen Chen
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, No.386, Dazhong 1st Rd., Zuoying Dist, Kaohsiung City, 81362, Taiwan
| | - Li-Te Lin
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, No.386, Dazhong 1st Rd., Zuoying Dist, Kaohsiung City, 81362, Taiwan. .,Institute of Biopharmaceutical Sciences, National Sun Yat-sen University, Kaohsiung City, Taiwan. .,Department of Obstetrics and Gynecology, School of Medicine, National Yang-Ming University, Taipei City, Taiwan. .,Department of Biological Science, National Sun Yat-sen University, Kaohsiung City, Taiwan.
| | - Kuan-Hao Tsui
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, No.386, Dazhong 1st Rd., Zuoying Dist, Kaohsiung City, 81362, Taiwan. .,Institute of Biopharmaceutical Sciences, National Sun Yat-sen University, Kaohsiung City, Taiwan. .,Department of Obstetrics and Gynecology, School of Medicine, National Yang-Ming University, Taipei City, Taiwan. .,Department of Biological Science, National Sun Yat-sen University, Kaohsiung City, Taiwan.
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Ma J, Gao W, Li D. Recurrent implantation failure: A comprehensive summary from etiology to treatment. Front Endocrinol (Lausanne) 2023; 13:1061766. [PMID: 36686483 PMCID: PMC9849692 DOI: 10.3389/fendo.2022.1061766] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/13/2022] [Indexed: 01/06/2023] Open
Abstract
Implantation is the first step in human reproduction. Successful implantation depends on the crosstalk between embryo and endometrium. Recurrent implantation failure (RIF) is a clinical phenomenon characterized by a lack of implantation after the transfer of several embryos and disturbs approximately 10% couples undergoing in vitro fertilization and embryo transfer. Despite increasing literature on RIF, there is still no widely accepted definition or standard protocol for the diagnosis and treatment of RIF. Progress in predicting and preventing RIF has been hampered by a lack of widely accepted definitions. Most couples with RIF can become pregnant after clinical intervention. The prognosis for couples with RIF is related to maternal age. RIF can be caused by immunology, thrombophilias, endometrial receptivity, microbiome, anatomical abnormalities, male factors, and embryo aneuploidy. It is important to determine the most possible etiologies, and individualized treatment aimed at the primary cause seems to be an effective method for increasing the implantation rate. Couples with RIF require psychological support and appropriate clinical intervention. Further studies are required to evaluate diagnostic method and he effectiveness of each therapy, and guide clinical treatment.
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Affiliation(s)
- Junying Ma
- Center of Reproductive Medicine, Shengjing Hospital of China Medical University, Shenyang, China
- Key Laboratory of Reproductive and Genetic Medicine, China Medical University, National Health Commission, Shenyang, China
- Shengjing Hospital of China Medical University, Key Laboratory of Reproductive Dysfunction Diseases and Fertility Remodeling of Liaoning Province, Shenyang, China
| | - Wenyan Gao
- Department of Obstetrics, the First Affiliated Hospital of China Medical University, Shenyang, China
| | - Da Li
- Center of Reproductive Medicine, Shengjing Hospital of China Medical University, Shenyang, China
- Key Laboratory of Reproductive and Genetic Medicine, China Medical University, National Health Commission, Shenyang, China
- Shengjing Hospital of China Medical University, Key Laboratory of Reproductive Dysfunction Diseases and Fertility Remodeling of Liaoning Province, Shenyang, China
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Maghraby H, Abdelbadie AS, Aboali A, Elnashar A. GnRH agonist as a luteal support in IVF cycle: mini-review—is there a role? MIDDLE EAST FERTILITY SOCIETY JOURNAL 2022. [DOI: 10.1186/s43043-022-00109-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
It has been established that assisted reproductive technology (ART) cycles are usually accompanied by a defective luteal phase, and that luteal phase support (LPS) is mandatory to improve reproductive outcomes. This review aims to summarize the hypothesis, safety and current evidence about GnRH agonist as a luteal phase support in ART.
Main body
There are many regimens of luteal phase support to improve ART outcomes in women undergoing fresh and thawed cycles. Luteal phase support drugs include progesterone, human chorionic gonadotropin, gonadotropin-releasing hormone agonist, estradiol, and recombinant luteinizing hormone. There is some debate about optimal drugs and timing for start of LPS in ART cycles.
Conclusion
Although most centers support luteal phase by vaginal progesterone, GnRH agonist is a debatable drug for luteal support cycles.
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Fan Y, Sun YF, Xu YM, Cao ZY, Luo ZY, Sun Y, Zhao ZM, Hao GM, Gao BL. Factors affecting clinical pregnancy in controlled ovarian hyperstimulation with GnRH-a long protocol: a retrospective cross-sectional study. J OBSTET GYNAECOL 2022; 42:2486-2491. [PMID: 35678767 DOI: 10.1080/01443615.2022.2081490] [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: 10/18/2022]
Abstract
This retrospective cross-sectional study was to investigate factors affecting clinical pregnancy in patients who received gonadotropin-releasing hormone agonist luteal phase long protocol (GnRH-a long protocol) and underwent fresh in-vitro fertilisation (IVF)/intracytoplasmic sperm injection (ICSI) embryo transfer cycle. One thousand five hundred and twenty-five patients who received GnRH-a long protocol and underwent fresh IVF/ICSI embryo transfer cycle were enrolled. The clinical pregnancy rate (63.1 vs. 22.4%, p < .05) and live birth rate (53.8 vs. 14.5%, p < .05) were significantly higher while the miscarriage rate (12.5 vs. 35.3%, p < .05) was significantly lower in the two embryo group than those in the one embryo group. The clinical pregnancy rate (48.5 vs. 64.1%, p < .05) and live birth rate (38.4 vs. 55.0%, p < .05) were significantly lower in patients older than 33.5 years than those in younger patients. The clinical pregnancy rate (52 and 60.6 vs. 79.7%, p < .05) and live birth rate (36 and 51.4 vs. 69.6%, p < .05) of the thin and mediate groups were significantly lower than those in the thick group, whereas the ectopic pregnancy rate (11.5 and 1.9 vs. 0%, p < .05) was significantly higher in the thin group than in the mediate and thick group. Multivariate logistic regression analysis showed that age (OR = 0.956, 95% CI [0.931, 0.982], p < .05), number of embryos transferred (OR = 2.491, 95% CI [1.670, 3.715], p < .05) and endometrial thickness on the transplantation day (OR = 1.124, 95% CI [1.067, 1.185], p < .05) were independent factors significantly associated with clinical pregnancy. In conclusion, endometrial thickness (>14.69 mm) on the day of transfer, two cleavage embryos transferred, and female age (≤33.5 years) are independent factors affecting clinical pregnancy outcomes in controlled ovarian hyperstimulation with GnRH-a long protocol for assisted conception. IMPACT STATEMENTWhat is already known on this subject? Fresh embryo transfer cycle with GnRH-a long protocol will result in a higher pregnancy rate in controlled ovarian hyperstimulation cycles.What do the results of this study add? Endometrial thickness on the day of transfer, number of embryos transferred, and female age were independent factors affecting clinical pregnancy outcomes.What are the implications of these findings for clinical practice and/or further research? When performing a fresh IVF/ICSI embryo transfer cycle with GnRH-a long protocol for ovulation induction, the independent affecting factors should be taken into consideration.
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Affiliation(s)
- Yanli Fan
- Department of Reproductive Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Yi-Fei Sun
- Department of Reproductive Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Yue-Ming Xu
- Department of Reproductive Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Zi-Yu Cao
- Department of Reproductive Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Zhuo-Ye Luo
- Department of Reproductive Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Yong Sun
- Department of Reproductive Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Zhi-Ming Zhao
- Department of Reproductive Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Gui-Min Hao
- Department of Reproductive Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Bu-Lang Gao
- Department of Reproductive Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
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Liu Y, Wu Y, Pan Z, Jiang F, Lu Y, Meng Y. Single-Dose Versus Multiple-Dose GnRH Agonist for Luteal-Phase Support in Women Undergoing IVF/ICSI Cycles: A Network Meta-Analysis of Randomized Controlled Trials. Front Endocrinol (Lausanne) 2022; 13:802688. [PMID: 35432219 PMCID: PMC9008129 DOI: 10.3389/fendo.2022.802688] [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] [Received: 10/28/2021] [Accepted: 03/02/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Although gonadotropin-releasing hormone (GnRH) agonist has been introduced as a beneficial luteal phase support (LPS), the optimal strategy of GnRH agonist remains unclear. This network meta-analysis was therefore performed to determine the comparative efficacy and safety of multiple-dose versus single-dose GnRH agonist protocol for LPS in patients undergoing IVF/ICSI cycles. METHODS We searched relevant studies in PubMed, Embase and the Cochrane Registry of Controlled Trials (CENTRAL) from their inception util to September 2021. Live birth, clinical pregnancy rate, multiple pregnancy rate, and clinical abortion rate was evaluated. Pairwise and network meta-analysis were conducted using RevMan and ADDIS based on random-effects model, respectively. Moreover, the prioritization of protocols based on ranking probabilities for different outcomes were performed. RESULTS Sixteen RCTs met our eligibility criteria. Pairwise meta-analysis showed that multiple-dose protocol of GnRH agonist was effective for increasing live birth rate (OR 1.80, 95% CI 1.15 to 2.83, p=0.01) and clinical pregnancy rate (OR 1.89, 95% CI 1.01 to 3.56, p=0.05) as well as decreasing clinical abortion rate (OR 0.55, 95% CI 0.34 to 0.90, p=0.02). Meanwhile, single-dose protocol of GnRH agonist was effective for increasing clinical pregnancy rate (OR 1.45, 95% CI 1.11 to 1.89, p=0.007) and multiple pregnancy rate (OR 2.55, 95% CI 1.12 to 5.78, p=0.03). However, network meta-analysis only confirmed that multiple-dose protocol of GnRH agonist was the best efficacious strategy for live birth rate (OR 2.04, 95% CrI 1.19 to 3.93) and clinical pregnancy rate (OR 2.10, 95% CrI 1.26 to 3.54). CONCLUSION Based on the results of NMA, multiple-dose protocol may be the optimal strategy for patients undergoing IVF/ICSI cycles owing to its advantage in increasing live birth and clinical pregnancy rate. Moreover, single-dose protocol may be the optimal strategy for improving multiple pregnancy rate. However, with the limitations, more RCTs are required to confirm our findings.
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Affiliation(s)
| | | | | | | | - Youhui Lu
- *Correspondence: Yushi Meng, ; Youhui Lu,
| | - Yushi Meng
- *Correspondence: Yushi Meng, ; Youhui Lu,
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Zareii A, Davoodi S, Alborzi M, Moghadam ME, Askary E. Co-administration of GnRH agonists with vaginal progesterone compared to vaginal progesterone in luteal phase support of the frozen-thawed embryo transfer cycle: An RCT. Int J Reprod Biomed 2021; 19:863-872. [PMID: 34805726 PMCID: PMC8595909 DOI: 10.18502/ijrm.v19i10.9817] [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: 03/25/2020] [Revised: 09/01/2020] [Accepted: 11/24/2020] [Indexed: 12/02/2022] Open
Abstract
Background Since progesterone alone does not seem to be enough for luteal phase support (LPS), especially in frozen embryo transfer (FET) cycles, so gonadotropin-releasing hormone agonist (GnRH-a) is suggested as an adjuvant therapy in combination with progesterone for LPS. Objective To evaluate the effects of the administration of GnRH-a with vaginal progesterone compared to vaginal progesterone alone in luteal phase support of the frozen-thawed embryo transfer cycles. Materials and Methods In this randomized controlled clinical trial, 240 infertile women who were candidates for FET were evaluated into two groups (n = 120/each). Group I received 400 mg vaginal progesterone twice a day from the time of transfer. The second group received vaginal progesterone and also 0.1 mg diphereline on days 0, 3, and 6 of FET for LPS. Finally, the clinical and ongoing pregnancy rates, and the implantation, and spontaneous abortion rates were compared in two groups. Results Results showed that there was no significant difference between the mean age of women and the duration of infertility (p = 0.78, p = 0.58, respectively). There were no significant differences between groups in the terms of implantation and spontaneous abortion rates (p = 0.19, p = 0.31, respectively). However, in terms of clinical and ongoing pregnancy rates, the significant differences were seen between groups (p = 0.008 and p = 0.005, respectively). Conclusion Co-administration of GnRH-a and vaginal progesterone in LPS may be superior to vaginal progesterone alone in women who underwent a frozen-selected embryo transfer cycle.
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Affiliation(s)
- Afsoon Zareii
- Infertility Division, Infertility Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sara Davoodi
- Infertility Division, Infertility Research Center, Department of Obstetrics and Gynecology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahshid Alborzi
- Infertility Division, School of Medicine, Jahrom University of Medical Sciences, Jahrom, Iran
| | | | - Elham Askary
- Department of Obstetrics and Gynecology, Laparoscopy Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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10
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Dashti S, Eftekhar M. Luteal-phase support in assisted reproductive technology: An ongoing challenge. Int J Reprod Biomed 2021; 19:761-772. [PMID: 34723055 PMCID: PMC8548747 DOI: 10.18502/ijrm.v19i9.9708] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 12/02/2020] [Accepted: 12/12/2020] [Indexed: 01/06/2023] Open
Abstract
It has been shown that in controlled ovarian hyper stimulation cycles, defective
luteal phase is common. There are many protocols for improving pregnancy
outcomes in women undergoing fresh and frozen in vitro fertilization cycles.
These approaches include progesterone supplements, human chorionic gonadotropin,
estradiol, gonadotropin-releasing hormone agonist, and recombinant luteinizing
hormone. The main challenge is luteal-phase support (LPS) in cycles with
gonadotropin-releasing hormone agonist triggering. There is still controversy
about the optimal component and time for starting LPS in assisted reproductive
technology cycles. This review aims to summarize the various protocols suggested
for LPS in in vitro fertilization cycles.
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Affiliation(s)
- Saeideh Dashti
- Research and Clinical Center for Infertility, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Maryam Eftekhar
- Research and Clinical Center for Infertility, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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Mutlu I, Demirdag E, Cevher F, Erdem A, Erdem M. Dual trigger with the combination of gonadotropin-releasing hormone agonist and standard dose of human chorionic gonadotropin improves in vitro fertilisation outcomes in poor ovarian responders. J OBSTET GYNAECOL 2021; 42:1239-1244. [PMID: 34565274 DOI: 10.1080/01443615.2021.1945560] [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: 10/20/2022]
Abstract
The study aimed to evaluate the impact of the dual trigger with the combination of GnRH agonist and standard dose of recombinant hCG on IVF outcomes in poor ovarian responders with GnRH antagonist protocol. 1283 cycles of 1010 poor responder patients according to Bologna criteria were retrospectively analysed in terms of final oocyte maturation: dual trigger group (250 μg hCG + 0.2 mg triptorelin) or standard group (250 μg hCG). Primary outcome measures were the number of retrieved and mature oocytes. The secondary outcome measures were clinical pregnancy rates and live birth rates.The number of retrieved oocytes, mature oocytes, and the top-quality embryos transferred were significantly higher in the dual trigger group (p < .001). Fertilisation rates (73.6% vs 69.6%, p = .009), implantation rates (18.7% vs 14.6, p = .039), clinical pregnancy rate per embryo transfer (27.5% vs. 19.9%, p = .010) and live birth rate per embryo transfer (21.6% vs. 14.9%, p = .011) were also significantly higher in the dual trigger group as compared to the hCG trigger group. The usage of dual trigger with a GnRH agonist and a standard dosage of hCG could improve clinical pregnancy rates and live birth rates in poor ovarian responders undergoing GnRH antagonist IVF/ICSI cycles.IMPACT STATEMENTWhat is already known on this subject? Dual trigger with standard dose of hCG has been the subject of trials in normal responders to optimise IVF outcomes. The results of these studies showed significant improvements in implantation and pregnancy rates with an increase in the number of mature oocytes retrieved. As a result, dual trigger has become a popular ovulation trigger option in GnRH antagonist cycles.What do the results of this study add? There is limited data about the use of dual trigger in poor ovarian responders (PORs). According to our study, increasing the number of retrieved oocytes, mature oocytes, the number of fertilised oocytes, the number of transferred embryos and top quality embryos transferred by using dual trigger in patients with PORs have a positive impact on pregnancy outcomes.What are the implications of these findings for clinical practice and/or further research? These findings implies potential advantages of dual trigger usage for improving IVF outcomes in PORs. With large sample sized prospective randomised trials, dual trigger with combination of GnRHa and a standard dose of hCG might replace the traditional ovulation trigger with hCG in PORs.
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Affiliation(s)
- Ilknur Mutlu
- IVF Unit, Novaart IVF and Women Health Center, Ankara, Turkey
| | - Erhan Demirdag
- Department of Obstetrics & Gynecology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Funda Cevher
- Department of Obstetrics & Gynecology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Ahmet Erdem
- Department of Obstetrics & Gynecology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Mehmet Erdem
- Department of Obstetrics & Gynecology, Gazi University Faculty of Medicine, Ankara, Turkey
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Xu B, Geerts D, Hu S, Yue J, Li Z, Zhu G, Jin L. The depot GnRH agonist protocol improves the live birth rate per fresh embryo transfer cycle, but not the cumulative live birth rate in normal responders: a randomized controlled trial and molecular mechanism study. Hum Reprod 2021; 35:1306-1318. [PMID: 32478400 DOI: 10.1093/humrep/deaa086] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 03/23/2020] [Indexed: 12/20/2022] Open
Abstract
STUDY QUESTION Do cumulative live birth rates (CLBRs) after one complete ART cycle differ between the three commonly used controlled ovarian stimulation (COS) protocols (GnRH antagonist, depot GnRHa (GnRH agonist) and long GnRHa) in normal responders undergoing IVF/ICSI? SUMMARY ANSWER There were similar CLBRs between the GnRH antagonist, depot GnRHa and long GnRHa protocols. WHAT IS KNOWN ALREADY There is no consensus on which COS protocol is the most optimal in women with normal ovarian response. The CLBR provides the final success rate after one complete ART cycle, including the fresh and all subsequent frozen-thawed embryo transfer (ET) cycles. We suggest that the CLBR measure would allow for better comparisons between the different treatment protocols. STUDY DESIGN, SIZE, DURATION A prospective controlled, randomized, open label trial was performed between May 2016 and May 2017. A total of 819 patients were allocated to the GnRH antagonist, depot GnRHa or long GnRHa protocol in a 1:1:1 ratio. The minimum follow-up time from the first IVF cycle was 2 years. To further investigate the potential effect of COS with the GnRH antagonist, depot GnRHa or long GnRHa protocol on endometrial receptivity, the expression of homeobox A10 (HOXA10), myeloid ecotropic viral integration site 1 (MEIS1) and leukemia inhibitory factor (LIF) endometrial receptivity markers was evaluated in endometrial tissue from patients treated with the different COS protocols. PARTICIPANTS/MATERIALS, SETTING, METHODS Infertile women with normal ovarian response (n = 819) undergoing IVF/ICSI treatment were randomized to the GnRH antagonist, depot GnRHa or long GnRHa protocol. Both IVF and ICSI cycles were included, and the sperm samples used were either fresh or frozen partner ejaculates or frozen donor ejaculates. The primary outcome was the live birth rate (LBR) per fresh ET cycle, and the CLBR after one complete ART cycle, until the birth of a first child (after 28 weeks) or until all frozen embryos were used, whichever occurred first. Pipelle endometrial biopsies from 34 female patients were obtained on Days 7-8 after oocyte retrieval or spontaneous ovulation in natural cycles, respectively, and HOXA10, MEIS1 and LIF mRNA and protein expression levels in the human endometrium was determined by quantitative real-time PCR and western blot, respectively. MAIN RESULTS AND THE ROLE OF CHANCE There were no significant differences in CLBRs between the GnRH antagonist, depot GnRHa or long GnRHa protocol (71.4 versus 75.5 versus 72.2%, respectively). However, there was a significantly higher LBR per fresh ET cycle in the depot GnRHa protocol than in the long GnRHa and GnRH antagonist protocols (62.6 versus 52.1% versus 45.6%, P < 0.05). Furthermore, HOXA10, MEIS1 and LIF mRNA and protein expression in endometrium all showed significantly higher in the depot GnRHa protocol than in the long GnRHa and GnRH antagonist protocols (P < 0.05). LIMITATIONS, REASONS FOR CAUTION A limitation of our study was that both our clinicians and patients were not blinded to the randomization for the randomized controlled trial (RCT). An inclusion criterion for the current retrospective cohort study was based on the 'actual ovarian response' during COS treatment, while the included population for the RCT was 'expected normal responders' based on maternal age and ovarian reserve test. In addition, the analysis was restricted to patients under 40 years of age undergoing their first IVF cycle. Furthermore, the endometrial tissue was collected from patients who cancelled the fresh ET, which may include some patients at risk for ovarian hyperstimulation syndrome, however only patients with 4-19 oocytes retrieved were included in the molecular study. WIDER IMPLICATIONS OF THE FINDINGS The depot GnRH agonist protocol improves the live birth rate per fresh ET cycle, but not the cumulative live birth rate in normal responders. A possible explanation for the improved LBR after fresh ET in the depot GnRHa protocol could be molecular signalling at the level of endometrial receptivity. STUDY FUNDING/COMPETING INTEREST(S) This project was funded by Grant 81571439 from the National Natural Sciences Foundation of China and Grant 2016YFC1000206-5 from the National Key Research & Development Program of China. The authors declare no conflict of interest. TRIAL REGISTRATION NUMBER The RCT trial was registered at the Chinese Clinical Trial Registry, Study Number: ChiCTR-INR-16008220. TRIAL REGISTRATION DATE 5 April 2016. DATE OF FIRST PATIENT’S ENROLLMENT 12 May 2016.
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Affiliation(s)
- Bei Xu
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, 1095 JieFang Avenue, Wuhan 430030, People's Republic of China
| | - Dirk Geerts
- Department of Medical Biology, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Shiqiao Hu
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, 1095 JieFang Avenue, Wuhan 430030, People's Republic of China
| | - Jing Yue
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, 1095 JieFang Avenue, Wuhan 430030, People's Republic of China
| | - Zhou Li
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, 1095 JieFang Avenue, Wuhan 430030, People's Republic of China
| | - Guijin Zhu
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, 1095 JieFang Avenue, Wuhan 430030, People's Republic of China
| | - Lei Jin
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, 1095 JieFang Avenue, Wuhan 430030, People's Republic of China
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Qu D, Li Y. Multiple-dose versus single-dose gonadotropin-releasing hormone agonist after first in vitro fertilization failure associated with luteal phase deficiency: A randomized controlled trial. J Int Med Res 2021; 48:300060520926026. [PMID: 32495663 PMCID: PMC7273566 DOI: 10.1177/0300060520926026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To evaluate the efficacy and safety of multiple- versus single-dose gonadotropin-releasing hormone agonist (GnRH-a) addition to luteal phase support (LPS), in patients with a first in vitro fertilization (IVF) failure associated with luteal phase deficiency (LPD). Methods Eighty patients with a first IVF failure associated with LPD were randomly assigned into single-dose and multiple-dose GnRH-a groups. In the second IVF attempt, patients in the single-dose group were given standard LPS plus a single dose of GnRH-a 6 days after oocyte retrieval. Patients in the multiple-dose group received standard LPS plus 14 daily injections of GnRH-a. Children conceived were followed up for 2 years. Results Pregnancy (67.5% vs. 42.5%), clinical pregnancy (50.0% vs. 22.5%), and live birth rates (42.5% vs. 20.0%) were significantly higher in the multiple-dose versus single-dose GnRH-a group. Patients in the multiple-dose GnRH-a group had significantly higher progesterone levels 14 days after oocyte recovery (35.9 vs. 21.4 ng/mL). No significant difference existed in the status at birth or developmental and behavior assessments of 2-year-old children conceived in both groups. Conclusions Daily addition of GnRH-a to standard LPS can achieve better pregnancy outcomes with a sustained safety profile in patients with a first IVF failure associated with LPD.
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Affiliation(s)
- Danni Qu
- Medical Center for Human Reproduction, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yuan Li
- Medical Center for Human Reproduction, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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14
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Xu J, Li SZ, Yin MN, Liang PL, Li P, Sun L. Endometrial Preparation for Frozen-Thawed Embryo Transfer With or Without Pretreatment With GnRH Agonist: A Randomized Controlled Trial at Two Centers. Front Endocrinol (Lausanne) 2021; 12:722253. [PMID: 34733238 PMCID: PMC8559785 DOI: 10.3389/fendo.2021.722253] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 09/20/2021] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE This prospective randomized controlled trial compared the reproductive outcomes of frozen embryo transfer (FET) with hormone replacement treatment (HRT) with or without gonadotropin-releasing hormone agonist (GnRHa) pretreatment. METHODS A total of 133 patients scheduled for HRT-FET mainly because of tubal and/or male factors who received two high-quality cleavage-stage embryos were enrolled at two participating centers. The GnRHa group (n = 65) received GnRHa pretreatment, while the control group (n = 68) did not. Analysis was based on the intention-to-treat (ITT) principle. RESULTS Among the 133 participants, 130 (97.7%) underwent embryo transfer and 127 (95.5%) completed the protocol. The clinical pregnancy rate according to ITT did not differ between the GnRHa and control groups [39/65 (60.0%) vs. 41/68 (60.3%), p = 0.887]. The implantation rate (47.6% vs. 45.3%, p = 0.713), early pregnancy loss rate (5.1% vs. 19.5%, p = 0.09), and live birth rate (49.2% vs. 50.0%, p = 0.920) were also comparable between groups. CONCLUSION Pretreatment with GnRHa does not improve the reproductive outcomes for women receiving HRT-FET. CLINICAL TRIAL REGISTRATION The study was registered with the Chinese Clinical Trial Registry (ChiCTR-IOR-17014170; http://www.chictr.org.cn).
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Affiliation(s)
- Jian Xu
- Center of Reproductive Medicine, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Shu-Zhen Li
- Reproductive Medicine center, Jiangmen Central Hospital, Affiliated Hospital of Sun Yat-Sen University, Jiangmen, China
| | - Min-Na Yin
- Center of Reproductive Medicine, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Pei-Ling Liang
- Center of Reproductive Medicine, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Ping Li
- Reproductive Medicine center, Jiangmen Central Hospital, Affiliated Hospital of Sun Yat-Sen University, Jiangmen, China
- *Correspondence: Ling Sun, ; Ping Li,
| | - Ling Sun
- Center of Reproductive Medicine, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- *Correspondence: Ling Sun, ; Ping Li,
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15
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Saharkhiz N, Salehpour S, Hosseini S, Hosseinirad H, Nazari L. Effects of gonadotropin-releasing hormone agonist (GnRH-a) as luteal phase support in intracytoplasmic sperm injection (ICSI) cycles: a randomized controlled trial. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2020. [DOI: 10.1186/s43043-020-00030-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
This paper describes a blind randomized controlled trial (RCT) designed to evaluate the effect of gonadotropin-releasing hormone agonist (GnRH-a) administration on outcomes of intracytoplasmic sperm injection (ICSI) in subjects stimulated with the gonadotropin-releasing hormone (GnRH) antagonist protocol. A total of 268 women who underwent ICSI cycles with GnRH antagonist ovarian stimulation protocol were included in the study. Patients were randomly assigned to the intervention (GnRH-a) and control groups. The intervention group received a single dose injection of triptorelin (0.1 mg) subcutaneously 6 days after oocyte retrieval while the control group received placebo. The rates of chemical and clinical pregnancy were defined as the primary outcome values.
Results
Two hundred forty participants accomplished the study, and their data were analyzed. No significant difference was detected between the chemical pregnancy rates of the intervention and control groups. However, the clinical pregnancy rate was significantly higher in the GnRH-a group than in the placebo group.
Conclusions
The findings of the present study suggest that the GnRH-a support in the luteal phase can result in a significant improvement of pregnancy rates in ICSI cycles following the ovarian stimulation with GnRH antagonist protocol.
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16
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Song M, Liu C, Hu R, Wang F, Huo Z. Administration effects of single-dose GnRH agonist for luteal support in females undertaking IVF/ICSI cycles: A meta-analysis of randomized controlled trials. Exp Ther Med 2019; 19:786-796. [PMID: 31885714 DOI: 10.3892/etm.2019.8251] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 09/13/2019] [Indexed: 11/06/2022] Open
Abstract
The aim of the present meta-analysis was to evaluate the effects of the addition of single-dose gonadotropin-releasing hormone agonist (GnRHa) for luteal support on pregnancy outcomes in females partaking in in vitro fertilization or intracytoplasmic sperm injection cycles. In total, the studies were hand-searched from six electronic databases to compare the pregnancy outcomes between single-dose GnRHa administered as luteal phase support (GnRHa group) and regular luteal support (control group). In the GnRHa group, single-dose GnRH agonist were administered at 5/6 days after IVF/ICSI procedures. In the control group, single-dose GnRH agonist was not added during luteal phase support. Only randomized controlled trials were included. Sensitivity analysis was performed using Revman 5.3 software; the high heterogeneity identified in the present analysis was primarily caused by one study included. Following exclusion of this particular study, the meta-analysis results indicated significantly higher rates of ongoing pregnancy or live birth per transfer (P=0.002), clinical pregnancy per transfer (CPR; P=0.001) and multiple pregnancy per pregnancy (P=0.020) in the GnRHa group compared with those in the control group. Meta-analysis of a subgroup of trials with long-acting GnRH-a ovarian treatment protocols indicated that the rate of ongoing pregnancy or live birth (P=0.080), CPR (P=0.090) and multiple pregnancy per pregnancy (P=0.140) were not significantly different between the two groups. However, the results from trials that had used a multi-dose GnRH antagonist ovarian treatment protocol indicated a significantly higher ongoing pregnancy or live birth rate per transfer (P=0.010), CPR per transfer (P<0.0001) and multiple pregnancy rate per pregnancy (P=0.003) compared with those in the control group. The present results suggested that administration of single-dose GnRH agonist in the luteal phase may be an ideal choice for patients undergoing IVF/ICSI therapy.
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Affiliation(s)
- Mengling Song
- Department of Reproductive Medicine, General Hospital of Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750004, P.R. China.,Key Laboratory of Fertility Preservation and Maintenance of Ministry of Education, Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750004, P.R. China
| | - Chunlian Liu
- Department of Reproductive Medicine, General Hospital of Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750004, P.R. China.,Key Laboratory of Fertility Preservation and Maintenance of Ministry of Education, Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750004, P.R. China
| | - Rong Hu
- Department of Reproductive Medicine, General Hospital of Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750004, P.R. China.,Key Laboratory of Fertility Preservation and Maintenance of Ministry of Education, Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750004, P.R. China
| | - Feimiao Wang
- Department of Reproductive Medicine, General Hospital of Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750004, P.R. China.,Key Laboratory of Fertility Preservation and Maintenance of Ministry of Education, Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750004, P.R. China
| | - Zhenghao Huo
- Key Laboratory of Fertility Preservation and Maintenance of Ministry of Education, Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750004, P.R. China
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Fusi FM, Brigante CM, Zanga L, Mignini Renzini M, Bosisio C, Fadini R. GnRH agonists to sustain the luteal phase in antagonist IVF cycles: a randomized prospective trial. Reprod Biol Endocrinol 2019; 17:103. [PMID: 31783862 PMCID: PMC6884808 DOI: 10.1186/s12958-019-0543-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 11/12/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The addition of a GnRH analogue to the luteal phase in in vitro fertilization programs has been seldom proposed due to the presence of GnRH receptors in the endometrium. The aim of the study was to evaluate the effect of triptorelin addition in short antagonist cycles, compared to cycles where the only supplementation was progesterone. METHODS The primary objective of this study was the study of the effect of Triptorelin addiction during the luteal phase on the live birth rate. Secondary objectives of efficacy were pregnancy rates and implantation rates, as well as safety in terms of OHSS risks. The study was a prospective, randomized, open study, performed in two independent Centers from July 2013 to October 2015. Patients were divided into three groups: a) Regular antagonist protocol, with only luteal progesterone; b) Antagonist protocol with luteal triptorelin as multiple injections, c) Antagonist protocol with luteal triptorelin as single bolus. Descriptive statistics were obtained for all the parameters. Mean and standard deviation were used for all quantitative parameters. Differences between percentages were studied using Chi-square test generalized to the comparison of several proportions. RESULTS A total number of 1344 patients completed the study, 786 under the age of 35 years, and 558 over 35 years. It was observed an increase of positive HCG results, Clinical pregnancy rates and Delivery rates when triptorelin was added in the luteal phase, irrespective whether as a single bolus or five injections. This increase was statistically significant both for pregnancy rates and delivery rates. The statistic difference between pregnancies and deliveries obtained with or without luteal triptorelin reached p < 0,01. No increase of OHSS risk was observed. CONCLUSIONS From this large study it appears that the concept of luteal phase supplementation should be revisited. From our study it appears that triptorelin addition to the luteal phase of antagonist cycles, either as a single bolus or using multiple injections, is a good tool to optimize ART results. TRIAL REGISTRATION The study was approved by the Ethics Committee of Provincia di Bergamo (n 1203/2013).
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Affiliation(s)
- Francesco M. Fusi
- ASST Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy
- 0000 0004 1757 2822grid.4708.bUniversità degli Studi Bicocca, Milan, Italy
| | - Claudio M. Brigante
- Biogenesi Reproductive Medicine Center , Istituti Clinici Zucchi, Monza, Italy
| | - Laura Zanga
- ASST Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy
| | | | - Chiara Bosisio
- ASST Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy
| | - Rubens Fadini
- Biogenesi Reproductive Medicine Center , Istituti Clinici Zucchi, Monza, Italy
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Embryo transfer strategy and therapeutic options in infertile patients with thin endometrium: a systematic review. J Assist Reprod Genet 2019; 36:2217-2231. [PMID: 31502111 DOI: 10.1007/s10815-019-01576-w] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 08/28/2019] [Indexed: 10/26/2022] Open
Abstract
Human endometrium has a key role in implantation process. The measurement of endometrial thickness is the most commonly used in clinical practice. Managing patients with thin endometrium still represents a major challenge for clinicians. The objective of this systematic review was to investigate all available interventions to improve endometrial thickness (EMT) in women with history of thin endometrium undergoing fresh or frozen-thawed embryo transfers (ET). We performed a comprehensive search of relevant studies from January 1978 to February 2018. The different strategies were categorized as hormonal, vascular, and growth factor approaches and specifically analyzed according to the type of ET. Thirty-one studies were included. Overall, quality of the evidence ranged from very low to moderate, with only few randomized controlled trials that support the use of either GnRH analogues in fresh ET or sildenafil in frozen ET for enhancing endometrial growth. Besides, intensified estradiol administration is a common approach that might improve EMT in frozen ET. The present review evidences the paucity of reliable data regarding the efficiency of different interventions aiming at increasing EMT before fresh or frozen-thawed ET. Robust and high-quality randomized controlled trials are still needed before guidelines can be established.
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19
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Wu L, Ren XL, Chen W, Huang B, Zhou YF, Jin L. Influence of Different Gonadotropin-releasing Hormone Agonist Administration Methods on Pregnancy Outcomes of Patients Undergoing In-vitro Fertilization-embryo Transfer. Curr Med Sci 2019; 39:437-441. [PMID: 31209816 DOI: 10.1007/s11596-019-2056-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 11/30/2018] [Indexed: 11/25/2022]
Abstract
This study aimed to investigate the effect of different gonadotropin-releasing hormone agonist (GnRH-a) administration methods on pregnancy outcomes of patients undergoing in-vitro fertilization-embryo transfer (IVF-ET). Clinical data of 5217 patients who underwent IVF-ET were retrospectively analyzed. Patients were divided into the long-acting GnRH-a group (n=1330) and the short-acting GnRH-a group (n=3887) based on their various treatment plans. The clinical and laboratory embryo data and clinical pregnancy outcomes were compared between the two groups. The results showed that there were no significant differences in the age, infertility, primary/secondary infertility rate, IVF rate, body mass index (BMI), antral follicle counting (AFC), follicle-stimulating hormone (FSH) level, and the number of transplanted embryos between the two groups (P>0.05). There were no significant differences in the oocyte numbers, MII rate, fertilization rate, cleavage rate and blastocyst formation rate (P>0.05) between the two groups. The gonadotropin (Gn) using days, Gn dose and endometrial thickness were significantly greater in the long-acting GnRH-a group than those in the short-acting GnRH-a group (P<0.01). Additionally, the estradiol (E2) levels, blastocyst freezing rate, embryo utilization rate, transplant cancellation rate and abortion rate were significantly lower in the long-acting GnRH-a group than those in the short-acting GnRH-a group (P<0.01). The clinical pregnancy rate and embryo implantation rate were significantly higher in the long-acting GnRH-a group than in the short-acting GnRH-a group (P<0.01). It was concluded that use of long-acting GnRH-a can effectively reduce the transplant cancellation rate and improve the clinical pregnancy rate of the fresh cycle.
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Affiliation(s)
- Li Wu
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xin-Ling Ren
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Wen Chen
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Bo Huang
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yi-Fan Zhou
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Lei Jin
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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Chau LTM, Tu DK, Lehert P, Dung DV, Thanh LQ, Tuan VM. Clinical pregnancy following GnRH agonist administration in the luteal phase of fresh or frozen assisted reproductive technology (ART) cycles: Systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol X 2019; 3:100046. [PMID: 31403130 PMCID: PMC6687475 DOI: 10.1016/j.eurox.2019.100046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 04/25/2019] [Accepted: 05/10/2019] [Indexed: 11/19/2022] Open
Abstract
Objective(s) To study if the GnRH agonist administration in luteal phase improves clinical pregnancy rate of fresh and frozen embryo transfer. Also, this meta-analysis compares the treatment effect of luteal GnRH agonist administration between long agonist and antagonist protocols of fresh cycles, and between two types of treatment: fresh and frozen embryo transfers. Study design Systematic review and meta-analysis (registration number CRD42017059152) Results For the overall 20 studies (5497 patients), clinical pregnancy rate significantly increased in group of GnRH agonist administration compared to control group (RR 1.24, 95% CI 1.14–1.34, p < 0.0001). Regarding the treatment effect of luteal GnRH agonist administration between long agonist and antagonist protocol fresh cycles, no significant difference was observed (RR = 1.28, 95% CI 0.98–1.67, p = 0.07). Also, in comparison between fresh and frozen embryo transfer, similar effect of GnRH agonist administration was found (RR = 0.93, 95% CI 0.74–1.16, p = 0.49). Conclusion(s) There is evidence that GnRH agonist administration in luteal phase improve clinical pregnancy rate in both fresh and frozen cycles. Within fresh cycles, no significant difference of clinical pregnancy rate is found between two protocols. In frozen cycles, the effect of GnRH agonist administration in enhancing clinical pregnancy rate is similar to fresh cycles.
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Affiliation(s)
- Le Thi Minh Chau
- Department of Infertility, Tu Du hospital, Vietnam
- Corresponding author at: Tu Du hospital.
| | | | - Philippe Lehert
- Faculty of Medicine, the University of Melbourne, Australia
- Faculty of Economics, UCL Mons, Louvain, Belgium
| | - Do Van Dung
- University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
| | | | - Vo Minh Tuan
- University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
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21
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Geng Y, Xun Y, Hu S, Lai Q, Jin L. GnRH antagonist versus follicular-phase single-dose GnRH agonist protocol in patients of normal ovarian responses during controlled ovarian stimulation. Gynecol Endocrinol 2019; 35:309-313. [PMID: 30430883 DOI: 10.1080/09513590.2018.1528221] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE This study aims to explore the differences of the ovarian stimulation (OS) characteristics, laboratory, and clinical outcomes between follicular-phase single-dose gonadotropin-releasing hormone (GnRH) agonist protocol and GnRH antagonist protocol during controlled ovarian hyperstimulation (COH). METHODS About 1883 consecutive IVF/ICSI fresh cycles of normal ovarian responders were retrospectively analyzed, with 1229 in the single-dose GnRH agonist protocol group and 654 in the GnRH antagonist protocol group at Reproductive Medical Center of Tongji Hospital from 1 January 2014 to 31 December 2017. RESULTS The follicular-phase single-dose GnRH agonist group showed significantly more oocytes obtained, higher implantation rate and pregnancy rate, as well as lower luteinizing hormone (LH) level and estradiol (E2)/oocyte ratio on the day of human chorionic gonadotropin (hCG) administration. However, differences were not significant in meiosis II (MII) oocyte rate, two pronuclear zygote (2PN) embryo rate, viable embryo rate or high-quality embryo rate, compared with the GnRH antagonist group. Further comparison of clinical outcomes in the first frozen-thawed cycles did not show significant difference in either implantation or clinical pregnancy rate between the two protocol groups. CONCLUSIONS Follicular-phase single-dose GnRH agonist protocol may achieve better clinical outcomes in normal ovarian responders, which could be explained more by positive effect on endometrial receptivity rather than embryo quality.
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Affiliation(s)
- Yudi Geng
- a Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan , People's Republic of China
| | - Yang Xun
- b Department of Urology , Tongji Hospital Tongji Medical College Huazhong University of Science and Technology , Wuhan , People's Republic of China
| | - Shiqiao Hu
- a Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan , People's Republic of China
| | - Qiaohong Lai
- a Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan , People's Republic of China
| | - Lei Jin
- a Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan , People's Republic of China
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Lin MH, Wu FSY, Hwu YM, Lee RKK, Li RS, Li SH. Dual trigger with gonadotropin releasing hormone agonist and human chorionic gonadotropin significantly improves live birth rate for women with diminished ovarian reserve. Reprod Biol Endocrinol 2019; 17:7. [PMID: 30609935 PMCID: PMC6320621 DOI: 10.1186/s12958-018-0451-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 12/27/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Diminished ovarian reserve (DOR) remains one of the greatest obstacles affecting the chance of a successful live birth after fertility treatment. The present study was set to investigate whether using a "dual trigger" consisted of human chorionic gonadotropin (hCG) plus gonadotropin releasing hormone agonist (GnRH-a) for final oocyte maturation could improve the IVF cycle outcomes for patients with diminished ovarian reserve. METHODS A total of 427 completed GnRH-antagonist downregulated IVF cycles with fresh embryo transfer (ET) were included in this retrospective analysis. DOR was defined as antral follicle count ≤5 and serum anti-Müllerian hormone level ≤ 1.1 ng/mL. The control group (n = 130) used a 6500 IU of recombinant hCG for trigger, and the study group (n = 297) used 0.2 mg of triptorelin plus 6500 IU of recombinant hCG for trigger. RESULTS The dual-trigger group had significantly higher oocyte fertilization rate (73.1% vs. 58.6%), clinical pregnancy rate (33.0% vs. 20.7%) and live birth rate (26.9% vs. 14.5%) when compared to the hCG trigger group. In addition, the abortion rate (17.4% vs. 37.0%) and embryo transfer cancellation rate (6.1% vs. 15.4%) were both significantly lower in the dual trigger group. The primary outcome measure was the live birth rate per oocyte retrieval cycle. Secondary outcome measures were embryo transfer cancellation rate, clinical pregnancy rate, implantation rate, chemical pregnancy rate and abortion rate per oocyte retrieval cycle. CONCLUSIONS Dual triggering the final oocyte maturation with GnRH-a and standard dose of hCG can significantly improve the live birth rate, clinical pregnancy rate, and fertilization rate in women with diminished ovarian reserve undergoing GnRH antagonist down-regulated IVF-ICSI cycles.
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Affiliation(s)
- Ming-Huei Lin
- 0000 0004 0573 007Xgrid.413593.9Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei, Taiwan
- 0000 0004 0573 007Xgrid.413593.9Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan
- Mackay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan
- 0000 0004 1762 5613grid.452449.aMackay Medical College, New Taipei City, Taiwan
| | - Frank Shao-Ying Wu
- IHMED Fertility Clinic, Taipei, Taiwan
- Taipei City Hospital, Heping-Fuyou Branch, Taipei, Taiwan
| | - Yuh-Ming Hwu
- 0000 0004 0573 007Xgrid.413593.9Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei, Taiwan
- 0000 0004 0573 007Xgrid.413593.9Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan
- Mackay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan
- 0000 0004 1762 5613grid.452449.aMackay Medical College, New Taipei City, Taiwan
| | - Robert Kuo-Kuang Lee
- 0000 0004 0573 007Xgrid.413593.9Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei, Taiwan
- 0000 0004 0573 007Xgrid.413593.9Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan
- 0000 0000 9337 0481grid.412896.0Department of Obstetrics and Gynecology, Taipei Medical University, Taipei, Taiwan
| | - Ryh-Sheng Li
- 0000 0004 0573 007Xgrid.413593.9Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Sheng-Hsiang Li
- 0000 0004 0573 007Xgrid.413593.9Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan
- Mackay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan
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Mid-luteal phase gonadotropin-releasing hormone agonist support in frozen-thawed embryo transfers during artificial cycles: A prospective interventional pilot study. J Gynecol Obstet Hum Reprod 2018; 47:391-395. [PMID: 29684629 DOI: 10.1016/j.jogoh.2018.04.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 04/15/2018] [Accepted: 04/17/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess the effect of an additional single mid-luteal dose of gonadotropin-releasing hormone agonist (GnRHa) on pregnancy and perinatal outcomes in hormonally substituted frozen embryo transfer (FET) cycles. STUDY DESIGN A prospective interventional pilot study. Women scheduled for FET were randomly selected to receive standard hormonal replacement therapy (HRT) for endometrial preparation or HRT with a single additional subcutaneous dose of 0.1mg triptorelin at the time of implantation. If FET was not followed by a pregnancy, women with surplus embryos were scheduled for a single second attempt in a crossover setting. Altogether, 144 FET cycles were analyzed. The carryover effect was tested using a logistic regression model. Logistic regression analysis for binary variables was applied with generalized estimation equation extension to account for dependence among repeated treatments. RESULTS The live birth rate (LBR) was 9.8 percentage points higher and the miscarriage rate 14.7 percentage points lower in the intervention group (n=72) than in the control group (n=72), but the differences did not reach statistical significance. Implantation and clinical pregnancy rates were comparable between the groups. No congenital malformations or differences in the median birth weight of newborns were detected. CONCLUSIONS Observable but statistically insignificant difference in LBR and miscarriage rate favoring luteal phase GnRHa support was detected. Further, no malformations or effect on fetal growth were observed. Larger studies are needed to confirm the results of this pilot study.
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Benmachiche A, Benbouhedja S, Zoghmar A, Boularak A, Humaidan P. Impact of Mid-Luteal Phase GnRH Agonist Administration on Reproductive Outcomes in GnRH Agonist-Triggered Cycles: A Randomized Controlled Trial. Front Endocrinol (Lausanne) 2017; 8:124. [PMID: 28663739 DOI: 10.3389/fendo.2017.00124/bibtex] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 05/22/2017] [Indexed: 05/28/2023] Open
Abstract
OBJECTIVE To explore whether the addition of a mid-luteal bolus of GnRH agonist (GnRHa) improves the implantation rate (IR) in in vitro fertilization (IVF) cycles. DESIGN A randomized controlled trial. SETTING Private IVF center. PATIENTS 328 IVF/intracytoplasmic sperm injection patients were triggered with GnRHa and received 1,500 IU HCG on the day of oocyte pick-up (OPU) in addition to a standard luteal phase support (LPS). INTERVENTIONS In addition, the study group received a bolus of GnRHa 6 days after OPU, whereas the control group did not. MAIN OUTCOME MEASURE Implantation rate. SECONDARY OUTCOME MEASURES Ongoing pregnancy (OP) and live birth (LB) rates. RESULTS Although serum concentrations of FSH, LH, E2, and P on day OPU + 7 were significantly higher in the study group compared to the control group, the IR was not statistically different between the treatment group (27%) and the control group (23%) [odds ratio (OR) 1.2 (95% CI 0.9-1.7), P < 0.27]. Similarly, the OP rate was 37% in the treatment group and 31% in the control group [OR 1.3 (95% CI 0.8-2.0), P < 0.23]. The LB rate was 36% in the treatment group and 31% in the control group [OR: 1.3 (95% CI 0.8-2.0), P < 0.27]. CONCLUSION Although a trend toward a higher IR and pregnancy rate was observed in the treatment group, this difference was not statistically significant. However, the absolute risk difference of 5% found for LB is clinically relevant, warranting further investigation. NCT 02053779.
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Affiliation(s)
| | - Sebti Benbouhedja
- Center for Reproductive Medicine, Clinique Ibn Rochd, Constantine, Algeria
| | - Abdelali Zoghmar
- Center for Reproductive Medicine, Clinique Ibn Rochd, Constantine, Algeria
| | - Amel Boularak
- Center for Reproductive Medicine, Clinique Ibn Rochd, Constantine, Algeria
| | - Peter Humaidan
- The Fertility Clinic, Skive Regional Hospital, Skive, Denmark
- Faculty of Health Aarhus University, Aarhus, Denmark
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25
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Increased Uterine NK cell numbers and perforin expression during the implantation phase in IVF Cycles with GnRH Antagonist Protocol. Sci Rep 2017; 7:39912. [PMID: 28045093 PMCID: PMC5206673 DOI: 10.1038/srep39912] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 11/29/2016] [Indexed: 01/02/2023] Open
Abstract
GnRH antagonist negatively affects endometrial receptivity in in vitro fertilization (IVF) cycles, however, its underlying mechanism remains unclear. To explore its target molecules, we studied endometria in the window phase of fixed GnRH antagonist, low-dose flexible GnRH antagonist, GnRH agonist long protocol, and untreated control groups. There were 384 differentially expressed genes (DEGs) in the fixed antagonist group with greater than twofold expression change compared with the control group and 197 DEGs between the fixed antagonist and agonist groups, the majority of which were associated with the natural killer (NK) cell-mediated cytotoxicity pathway. We then analysed the PRF1 and FASLG protein levels. The perforin level were significantly higher in both the antagonist groups than in other two groups, and was higher in the fixed antagonist group. Similarly, the uNK cell numbers were higher in the antagonist groups, and the highest uNK cell number occurred in the fixed group (p < 0.05). No significant differences existed in the Fas ligand levels and apoptosis rates among the three treatment groups, but were higher in the treatment groups than the control group. Together, these data indicate that GnRH antagonist may increase the uNK cell numbers and perforin expression, and this effect may be dose-dependent.
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26
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Benmachiche A, Benbouhedja S, Zoghmar A, Boularak A, Humaidan P. Impact of Mid-Luteal Phase GnRH Agonist Administration on Reproductive Outcomes in GnRH Agonist-Triggered Cycles: A Randomized Controlled Trial. Front Endocrinol (Lausanne) 2017; 8:124. [PMID: 28663739 PMCID: PMC5471294 DOI: 10.3389/fendo.2017.00124] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 05/22/2017] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To explore whether the addition of a mid-luteal bolus of GnRH agonist (GnRHa) improves the implantation rate (IR) in in vitro fertilization (IVF) cycles. DESIGN A randomized controlled trial. SETTING Private IVF center. PATIENTS 328 IVF/intracytoplasmic sperm injection patients were triggered with GnRHa and received 1,500 IU HCG on the day of oocyte pick-up (OPU) in addition to a standard luteal phase support (LPS). INTERVENTIONS In addition, the study group received a bolus of GnRHa 6 days after OPU, whereas the control group did not. MAIN OUTCOME MEASURE Implantation rate. SECONDARY OUTCOME MEASURES Ongoing pregnancy (OP) and live birth (LB) rates. RESULTS Although serum concentrations of FSH, LH, E2, and P on day OPU + 7 were significantly higher in the study group compared to the control group, the IR was not statistically different between the treatment group (27%) and the control group (23%) [odds ratio (OR) 1.2 (95% CI 0.9-1.7), P < 0.27]. Similarly, the OP rate was 37% in the treatment group and 31% in the control group [OR 1.3 (95% CI 0.8-2.0), P < 0.23]. The LB rate was 36% in the treatment group and 31% in the control group [OR: 1.3 (95% CI 0.8-2.0), P < 0.27]. CONCLUSION Although a trend toward a higher IR and pregnancy rate was observed in the treatment group, this difference was not statistically significant. However, the absolute risk difference of 5% found for LB is clinically relevant, warranting further investigation. NCT 02053779.
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Affiliation(s)
- Abdelhamid Benmachiche
- Center for Reproductive Medicine, Clinique Ibn Rochd, Constantine, Algeria
- *Correspondence: Abdelhamid Benmachiche,
| | - Sebti Benbouhedja
- Center for Reproductive Medicine, Clinique Ibn Rochd, Constantine, Algeria
| | - Abdelali Zoghmar
- Center for Reproductive Medicine, Clinique Ibn Rochd, Constantine, Algeria
| | - Amel Boularak
- Center for Reproductive Medicine, Clinique Ibn Rochd, Constantine, Algeria
| | - Peter Humaidan
- The Fertility Clinic, Skive Regional Hospital, Skive, Denmark
- Faculty of Health Aarhus University, Aarhus, Denmark
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27
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Seikkula J, Anttila L, Polo-Kantola P, Bloigu R, Engblom J, Tinkanen H, Jokimaa V. Effect of mid-luteal phase GnRH agonist on frozen-thawed embryo transfers during natural menstrual cycles: a randomised clinical pilot study. Gynecol Endocrinol 2016; 32:961-964. [PMID: 27348542 DOI: 10.1080/09513590.2016.1196176] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
This prospective randomised crossover study evaluated the effect of mid-luteal single-dose gonadotropin-releasing hormone agonist (triptoreline) on pregnancy outcomes in natural-cycle frozen embryo transfers (FETs). Ninety-eight women were randomised to receive either standard luteal support with vaginal micronised progesterone or an additional single dose of 0.1 mg triptoreline at the time of implantation. The intervention group was composed of 65 FET cycles and the control group of 62 cycles. In the intervention group, there were more positive pregnancy tests, clinical pregnancies and live births, but the differences did not reach statistical significance. The mean beta human chorionic gonadotropin (β-hCG) concentration of singleton pregnancies was significantly lower in the intervention group compared to the control group (p = 0.048). No difference was detected in the median birth weight of the newborns.
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Affiliation(s)
- Jaana Seikkula
- a Department of Obstetrics and Gynecology , Central Ostrobothnia Central Hospital , Kokkola , Finland
- b Department of Obstetrics and Gynecology , Turku University Hospital and University of Turku , Turku , Finland
| | | | - Päivi Polo-Kantola
- b Department of Obstetrics and Gynecology , Turku University Hospital and University of Turku , Turku , Finland
| | - Risto Bloigu
- d Medical Informatics and Statistics Research Group, University of Oulu , Oulu , Finland
| | - Janne Engblom
- e Department of Mathematics and Statistics , University of Turku , Turku , Finland , and
| | - Helena Tinkanen
- f Department of Obstetrics and Gynecology , Tampere University Hospital and University of Tampere , Tampere , Finland
| | - Varpu Jokimaa
- b Department of Obstetrics and Gynecology , Turku University Hospital and University of Turku , Turku , Finland
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28
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Kasum M, Kurdija K, Orešković S, Čehić E, Pavičić-Baldani D, Škrgatić L. Combined ovulation triggering with GnRH agonist and hCG in IVF patients. Gynecol Endocrinol 2016; 32:861-865. [PMID: 27275861 DOI: 10.1080/09513590.2016.1193141] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The aim of the review is to analyse the combination of a gonadotrophin releasing hormone (GnRH) agonist with a human chorionic gonadotrophin (hCG) trigger, for final oocyte maturation in in vitro fertilisation (IVF) cycles. The concept being a ''dual trigger'' combines a single dose of the GnRH agonist with a reduced or standard dosage of hCG at the time of triggering. The use of a GnRH agonist with a reduced dose of hCG in high responders demonstrated luteal phase support with improved pregnancy rates, similar to those after conventional hCG and a low risk of ovarian hyperstimulation syndrome (OHSS). The administration of a GnRH agonist and a standard hCG in normal responders, demonstrated significantly improved live-birth rates and a higher number of embryos of excellent quality, or cryopreserved embryos. The concept of the ''double trigger" represents a combination of a GnRH agonist and a standard hCG, when used 40 and 34 h prior to ovum pick-up, respectively. The use of the ''double trigger" has been successfully offered in the treatment of empty follicle syndrome and in patients with a history of immature oocytes retrieved or with low/poor oocytes yield. Further prospective studies are required to confirm the aforementioned observations prior to clinical implementation.
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Affiliation(s)
- Miro Kasum
- a Department of Obstetrics and Gynaecology , University Hospital Centre Zagreb, School of Medicine, University of Zagreb , Zagreb , Croatia and
| | - Kristijan Kurdija
- b Human Reproduction Unit, Maternity Hospital and Outpatient Clinic Podobnik , Zagreb , Croatia , and
| | - Slavko Orešković
- a Department of Obstetrics and Gynaecology , University Hospital Centre Zagreb, School of Medicine, University of Zagreb , Zagreb , Croatia and
| | - Ermin Čehić
- c Human Reproduction Unit, Cantonal Hospital Zenica , Zenica , Bosnia and Herzegovina
| | - Dinka Pavičić-Baldani
- a Department of Obstetrics and Gynaecology , University Hospital Centre Zagreb, School of Medicine, University of Zagreb , Zagreb , Croatia and
| | - Lana Škrgatić
- a Department of Obstetrics and Gynaecology , University Hospital Centre Zagreb, School of Medicine, University of Zagreb , Zagreb , Croatia and
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29
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Martins WP, Ferriani RA, Navarro PA, Nastri CO. GnRH agonist during luteal phase in women undergoing assisted reproductive techniques: systematic review and meta-analysis of randomized controlled trials. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:144-151. [PMID: 25854891 DOI: 10.1002/uog.14874] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 03/27/2015] [Accepted: 04/05/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To identify, evaluate and summarize the available evidence regarding the effectiveness and safety of administering a gonadotropin releasing hormone (GnRH) agonist during the luteal phase in women undergoing assisted reproductive techniques. METHODS In this systematic review and meta-analysis, we searched for randomized controlled trials (RCTs) comparing the addition of a GnRH agonist during the luteal phase, compared with standard luteal-phase support. We searched seven electronic databases and hand-searched the reference lists of included studies and related reviews. Our primary outcome was live birth or ongoing pregnancy per randomized woman. Our secondary outcomes were clinical pregnancy per randomized woman, miscarriage per clinical pregnancy, adverse perinatal outcome and congenital malformations. RESULTS The evidence from eight studies examining 2776 women showed a relative risk (RR) for live birth or ongoing pregnancy of 1.26 (95% CI, 1.04-1.53; I(2) = 58%). Sensitivity analysis when excluding the studies that did not report live birth and those at high risk of bias resulted in one study examining 181 women with an RR of 1.07 (95% CI, 0.73-1.58). Subgroup analysis separating the studies by single/multiple doses of GnRH agonists or by ovarian stimulation with GnRH agonist/antagonist was unable to explain the observed heterogeneity. The quality of the evidence was deemed to be very low: it was downgraded because of the limitation of the included studies, imprecision, inconsistency across the studies' results, and suspicion of publication bias. None of the included studies reported adverse perinatal outcomes or congenital malformations. CONCLUSIONS There is evidence that adding GnRH agonist during the luteal phase improves the likelihood of ongoing pregnancy. However, this evidence is of very low quality and there is no evidence for adverse perinatal outcome and congenital malformations. We therefore believe that including this intervention in clinical practice would be premature.
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Affiliation(s)
- W P Martins
- Department of Obstetrics and Gynecology, Ribeirao Preto Medical School, University of Sao Paulo (DGO-FMRP-USP), Ribeirao Preto, Brazil
| | - R A Ferriani
- Department of Obstetrics and Gynecology, Ribeirao Preto Medical School, University of Sao Paulo (DGO-FMRP-USP), Ribeirao Preto, Brazil
| | - P A Navarro
- Department of Obstetrics and Gynecology, Ribeirao Preto Medical School, University of Sao Paulo (DGO-FMRP-USP), Ribeirao Preto, Brazil
| | - C O Nastri
- Department of Obstetrics and Gynecology, Ribeirao Preto Medical School, University of Sao Paulo (DGO-FMRP-USP), Ribeirao Preto, Brazil
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Maggi R, Cariboni AM, Marelli MM, Moretti RM, Andrè V, Marzagalli M, Limonta P. GnRH and GnRH receptors in the pathophysiology of the human female reproductive system. Hum Reprod Update 2015; 22:358-81. [PMID: 26715597 DOI: 10.1093/humupd/dmv059] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 12/03/2015] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Human reproduction depends on an intact hypothalamic-pituitary-gonadal (HPG) axis. Hypothalamic gonadotrophin-releasing hormone (GnRH) has been recognized, since its identification in 1971, as the central regulator of the production and release of the pituitary gonadotrophins that, in turn, regulate the gonadal functions and the production of sex steroids. The characteristic peculiar development, distribution and episodic activity of GnRH-producing neurons have solicited an interdisciplinary interest on the etiopathogenesis of several reproductive diseases. The more recent identification of a GnRH/GnRH receptor (GnRHR) system in both the human endometrium and ovary has widened the spectrum of action of the peptide and of its analogues beyond its hypothalamic function. METHODS An analysis of research and review articles published in international journals until June 2015 has been carried out to comprehensively summarize both the well established and the most recent knowledge on the physiopathology of the GnRH system in the central and peripheral control of female reproductive functions and diseases. RESULTS This review focuses on the role of GnRH neurons in the control of the reproductive axis. New knowledge is accumulating on the genetic programme that drives GnRH neuron development to ameliorate the diagnosis and treatment of GnRH deficiency and consequent delayed or absent puberty. Moreover, a better understanding of the mechanisms controlling the episodic release of GnRH during the onset of puberty and the ovulatory cycle has enabled the pharmacological use of GnRH itself or its synthetic analogues (agonists and antagonists) to either stimulate or to block the gonadotrophin secretion and modulate the functions of the reproductive axis in several reproductive diseases and in assisted reproduction technology. Several inputs from other neuronal populations, as well as metabolic, somatic and age-related signals, may greatly affect the functions of the GnRH pulse generator during the female lifespan; their modulation may offer new possible strategies for diagnostic and therapeutic interventions. A GnRH/GnRHR system is also expressed in female reproductive tissues (e.g. endometrium and ovary), both in normal and pathological conditions. The expression of this system in the human endometrium and ovary supports its physiological regulatory role in the processes of trophoblast invasion of the maternal endometrium and embryo implantation as well as of follicular development and corpus luteum functions. The GnRH/GnRHR system that is expressed in diseased tissues of the female reproductive tract (both benign and malignant) is at present considered an effective molecular target for the development of novel therapeutic approaches for these pathologies. GnRH agonists are also considered as a promising therapeutic approach to counteract ovarian failure in young female patients undergoing chemotherapy. CONCLUSIONS Increasing knowledge about the regulation of GnRH pulsatile release, as well as the therapeutic use of its analogues, offers interesting new perspectives in the diagnosis, treatment and outcome of female reproductive disorders, including tumoral and iatrogenic diseases.
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Affiliation(s)
- Roberto Maggi
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via G. Balzaretti, 9, 20133 Milano, Italy
| | - Anna Maria Cariboni
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via G. Balzaretti, 9, 20133 Milano, Italy
| | - Marina Montagnani Marelli
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via G. Balzaretti, 9, 20133 Milano, Italy
| | - Roberta Manuela Moretti
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via G. Balzaretti, 9, 20133 Milano, Italy
| | - Valentina Andrè
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via G. Balzaretti, 9, 20133 Milano, Italy
| | - Monica Marzagalli
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via G. Balzaretti, 9, 20133 Milano, Italy
| | - Patrizia Limonta
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via G. Balzaretti, 9, 20133 Milano, Italy
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Gogce M, Benchaib M, Hadj S, Bordes A, du Menildot P, Lornage J, Salle B. Administration d’agonistes de la GnRH (Gonadotrophin Releasing Hormone) en phase lutéale des protocoles substitutifs de transferts d’embryons congelés : étude prospective randomisée. ACTA ACUST UNITED AC 2015; 43:728-34. [DOI: 10.1016/j.gyobfe.2015.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 07/07/2015] [Indexed: 11/27/2022]
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Şimşek E, Kılıçdağ EB, Aytaç PÇ, Çoban G, Şimşek SY, Çok T, Haydardedeoğlu B. Addition of gonadotropin releasing hormone agonist for luteal phase support in in-vitro fertilization: an analysis of 2739 cycles. J Turk Ger Gynecol Assoc 2015; 16:96-101. [PMID: 26097392 DOI: 10.5152/jtgga.2015.15007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 04/06/2015] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Luteal phase is defective in in vitro fertilization (IVF) cycles, and many regimens were tried for the very best luteal phase support (LPS). Gonadotropin releasing hormone (GnRH) agonist use, which was administered as an adjunct to the luteal phase support in IVF cycles, was suggested to improve pregnancy outcome measures in certain randomized studies. We analyzed the effects of addition of GnRH agonist to standard progesterone luteal support on pregnancy outcome measures, particularly the live birth rates. MATERIAL AND METHODS This is a retrospective cohort study, including 2739 IVF cycles. Long GnRH agonist and antagonist stimulation IVF cycles with cleavage-stage embryo transfer were included. Cycles were divided into two groups: Group A included cycles with single-dose GnRH agonist plus progesterone LPS and Group B included progesterone only LPS. Live birth rates were the primary outcome measures of the analysis. Miscarriage rates and multiple pregnancy rates were the secondary outcome measures. RESULTS Live birth rates were not statistically different in GnRH agonist plus progesterone (Group A) and progesterone only (Group B) groups in both the long agonist and antagonist stimulation arms (40.8%/41.2% and 32.8%/34.4%, p<0.05 respectively). Moreover, pregnancy rates, implantation rates, and miscarriage rates were found to be similar between groups. Multiple pregnancy rates in antagonist cycles were significantly higher in Group A than those in Group B (12.0% and 6.9%, respectively). CONCLUSION A beneficial effect of a single dose of GnRH agonist administration as a luteal phase supporting agent is yet to be determined because of the wide heterogeneity of data present in literature. Well-designed randomized clinical studies are required to clarify any effect of luteal GnRH agonist addition on pregnancy outcome measures with different doses, timing, and administration routes of GnRH agonists.
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Affiliation(s)
- Erhan Şimşek
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and IVF Unit, Başkent University Faculty of Medicine Adana Hospital, Adana, Turkey
| | - Esra Bulgan Kılıçdağ
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and IVF Unit, Başkent University Faculty of Medicine Adana Hospital, Adana, Turkey
| | - Pınar Çağlar Aytaç
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and IVF Unit, Başkent University Faculty of Medicine Adana Hospital, Adana, Turkey
| | - Gonca Çoban
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and IVF Unit, Başkent University Faculty of Medicine Adana Hospital, Adana, Turkey
| | - Seda Yüksel Şimşek
- Department of Obstetrics and Gynecology, Adana Maternity Hospital, Adana, Turkey
| | - Tayfun Çok
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and IVF Unit, Başkent University Faculty of Medicine Adana Hospital, Adana, Turkey
| | - Bülent Haydardedeoğlu
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and IVF Unit, Başkent University Faculty of Medicine Adana Hospital, Adana, Turkey
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Pirard C, Loumaye E, Laurent P, Wyns C. Contribution to More Patient-Friendly ART Treatment: Efficacy of Continuous Low-Dose GnRH Agonist as the Only Luteal Support-Results of a Prospective, Randomized, Comparative Study. Int J Endocrinol 2015; 2015:727569. [PMID: 25945092 PMCID: PMC4402188 DOI: 10.1155/2015/727569] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 03/18/2015] [Indexed: 11/18/2022] Open
Abstract
Background. The aim of this pilot study was to evaluate intranasal buserelin for luteal phase support and compare its efficacy with standard vaginal progesterone in IVF/ICSI antagonist cycles. Methods. This is a prospective, randomized, open, parallel group study. Forty patients underwent ovarian hyperstimulation with human menopausal gonadotropin under pituitary inhibition with gonadotropin-releasing hormone antagonist, while ovulation trigger and luteal support were achieved using intranasal GnRH agonist (group A). Twenty patients had their cycle downregulated with buserelin and stimulated with hMG, while ovulation trigger was achieved using 10,000 IU human chorionic gonadotropin with luteal support by intravaginal progesterone (group B). Results. No difference was observed in estradiol levels. Progesterone levels on day 5 were significantly lower in group A. However, significantly higher levels of luteinizing hormone were observed in group A during the entire luteal phase. Pregnancy rates (31.4% versus 22.2%), implantation rates (22% versus 15.4%), and clinical pregnancy rates (25.7% versus 16.7%) were not statistically different between groups, although a trend towards higher rates was observed in group A. No luteal phase lasting less than 10 days was recorded in either group. Conclusion. Intranasal administration of buserelin is effective for providing luteal phase support in IVF/ICSI antagonist protocols.
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Affiliation(s)
- Céline Pirard
- Department of Gynecology-Andrology, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, 1200 Brussels, Belgium
| | | | - Pascale Laurent
- Department of Gynecology-Andrology, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, 1200 Brussels, Belgium
| | - Christine Wyns
- Department of Gynecology-Andrology, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, 1200 Brussels, Belgium
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Wang X, Tsai T, Qiao J, Zhang Z, Feng HL. Impact of gonadotropins on oocyte maturation, fertilisation and developmental competence in vitro. Reprod Fertil Dev 2015; 26:752-7. [PMID: 23726536 DOI: 10.1071/rd13024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2013] [Accepted: 05/02/2013] [Indexed: 11/23/2022] Open
Abstract
The aim of the present study was to evaluate the dose-dependent effects of gonadotropins, either singly (Bravelle (B), Luveris (L), Menupur (M), Repronex (R), Gonal-F (G), Follism (F) and Norvarel (N)) or in combination (Menupur+Bravelle; Repronext+Bravelle; and Bravelle+Norvarel), on rates of oocyte maturation, fertilisation and early embryo development in vitro in an animal model. Bovine cumulus-oocyte complexes (COCs) were purchased commercially and cultured in TCM-199 with 10% fetal bovine serum supplemented with varying concentrations of gonadotropin (0, 5, 10, 20, 40IU or United States Pharmacopoeia (USP) mL-1) for 24 and 48h according to current IVF clinical stimulation protocols. All gonadotropins enhanced oocyte maturation in vitro in a dose-dependent manner. Individually, Gonal-F (Merck KGaA, Darmstadt, Germany), Follism (Merck Co, Whitehouse Station, NJ, USA) and Repronext (Ferring, Parsippany, NJ, USA) promoted oocyte maturation; in combination, they effectively enhanced COC expansion and increased the maturation competence of MII oocytes. However, high concentrations of gonadotropins may result in maturation arrest. Specific combinations of gonadotropins may change the rate of early embryonic development (8-16-cells) and morula-blastocyst formation. These data provide support for the responsiveness of bovine oocytes to gonadotropins in vitro and the need to consider variations in the relative concentrations and ratio of combinations (FSH/LH or human chorionic gonadotropin) for optimisation of oocyte developmental competence. The results of the present study could be applied to therapeutic clinical stimulation protocols and help improve IVF success rates.
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Affiliation(s)
- Xuemei Wang
- Department of Obstetrics and Gynecology, New York Hospital Queens, Weill Medical College of Cornell University, New York, NY 11355, USA
| | - Tony Tsai
- Department of Obstetrics and Gynecology, New York Hospital Queens, Weill Medical College of Cornell University, New York, NY 11355, USA
| | - Jie Qiao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100083, China
| | - Zhan Zhang
- Reproductive Medical Center, The Third Affiliated Hospital of Zhengzhou University, Henan, Zhengzhou , 450052, China
| | - Huai L Feng
- Department of Obstetrics and Gynecology, New York Hospital Queens, Weill Medical College of Cornell University, New York, NY 11355, USA
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Mesen TB, Young SL. Progesterone and the luteal phase: a requisite to reproduction. Obstet Gynecol Clin North Am 2015; 42:135-51. [PMID: 25681845 DOI: 10.1016/j.ogc.2014.10.003] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Progesterone production from the corpus luteum is critical for natural reproduction. Progesterone supplementation seems to be an important aspect of any assisted reproductive technology treatment. Luteal phase deficiency in natural cycles is a plausible cause of infertility and pregnancy loss, though there is no adequate diagnostic test. This article describes the normal luteal phase of the menstrual cycle, investigates the controversy surrounding luteal phase deficiency, and presents the current literature for progesterone supplementation during assisted reproductive technologies.
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Affiliation(s)
- Tolga B Mesen
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, CB 7570, Chapel Hill, NC 27599, USA.
| | - Steven L Young
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, CB 7570, Chapel Hill, NC 27599, USA
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Zafardoust S, Jeddi-Tehrani M, Akhondi MM, Sadeghi MR, Kamali K, Mokhtar S, Badehnoosh B, Arjmand-Teymouri F, Fatemi F, Mohammadzadeh A. Effect of Administration of Single Dose GnRH Agonist in Luteal Phase on Outcome of ICSI-ET Cycles in Women with Previous History of IVF/ICSI Failure: A Randomized Controlled Trial. J Reprod Infertil 2015; 16:96-101. [PMID: 25927026 PMCID: PMC4386092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 11/23/2014] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND GnRH agonist administration in the luteal phase has been suggested to beneficially affect the outcome of intracytoplasmic sperm injection (ICSI) and embryo transfer (ET) cycles. This blind randomized controlled study evaluates the effect of GnRH (Gonadotropine Releasing Hormone) agonist administration on ICSI outcome in GnRH antagonist ovarian stimulation protocol in women with 2 or more previous IVF/ICSI-ET failures. METHODS One hundred IVF failure women who underwent ICSI cycles and stimulated with GnRH antagonist ovarian stimulation protocol, were included in the study. Women were randomly assigned to intervention (received a single dose injection of GnRH agonist (0.1 mg of Decapeptil) subcutaneously 6 days after oocyte retrieval) and control (did not receive GnRH agonist) groups. Implantation and clinical pregnancy rates were the primary outcome measures. RESULTS Although the age of women, the number of embryos transferred in the current cycle and the quality of the transferred embryos were similar in the two groups, there was a significantly higher rate of implantation (Mann Whitney test, p = 0.041) and pregnancy (32.6% vs. 12.5%, p = 0.030, OR = 3.3, 95%CI, 1.08 to 10.4) in the intervention group. CONCLUSION Our results suggested that, in addition to routine luteal phase support using progesterone, administration of 0.1 mg of Decapeptil 6 days after oocyte retrieval in women with previous history of 2 or more IVF/ICSI failures led to a significant improvement in implantation and pregnancy rates after ICSI following ovarian stimulation with GnRH antagonist protocol.
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Affiliation(s)
- Simin Zafardoust
- Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran
| | - Mahmood Jeddi-Tehrani
- Reproductive Immunology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran
| | - Mohammad Mehdi Akhondi
- Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran
| | - Mohammad Reza Sadeghi
- Reproductive Immunology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran
| | - Koroush Kamali
- Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran
| | - Sara Mokhtar
- Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran
| | - Bita Badehnoosh
- Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran
| | | | - Farnaz Fatemi
- Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran
| | - Afsaneh Mohammadzadeh
- Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran,Corresponding Author: Afsaneh Mohammadzadeh, Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran. P.O box: 19615-1177, Postal code: 1936773493. E-mail:
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Fusi FM, Arnoldi M, Bosisio C, Lombardo G, Ferrario M, Zanga L, Galimberti A, Capitanio E. Ovulation induction and luteal support with GnRH agonist in patients at high risk for hyperstimulation syndrome. Gynecol Endocrinol 2015; 31:693-7. [PMID: 26527503 DOI: 10.3109/09513590.2015.1025379] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The aim of this study was to compare GnRHa trigger and luteal addition of triptorelin to hCG trigger for final oocyte maturation in women at high risk for OHSS undergoing IVF. A total of 423 patients were divided in two groups both stimulated using antagonist short protocol. Gonadotropins 75-150 UI/day were started on day 2-5, GnRH antagonist was added when the lead follicle was >14 mm and the final trigger was obtained with hCG 250 µg or triptorelin 0.2 mg. The luteal phase was supported with progesterone alone in the hCG group, with progesterone plus triptorelin 0.1 every other day from embryo transfer in the triptorelin group. In the triptorelin group we did neither have to suspend any embryo transfer, nor we have any early clinical OHSS. In the control group, 13 patients were suspended due to symptomatic high risk for OHSS and two patients developed a clinically significant OHSS. No statistically significant difference was observed in terms of clinical and ongoing pregnancy rates and implantation rates. Our results indicate that a protocol including GnRHa as trigger and an intensive luteal phase supported with GnRHa is safer than a standard antagonist protocol using hCG as trigger. It displays similar results, therefore it can be used as the first choice in patients at high risk for OHSS.
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Affiliation(s)
- Francesco M Fusi
- a Maternal and Pediatric Department , USSD Centro PMA, Ospedale Papa Giovanni XXIII , Bergamo , Italy and
- b School of Obstetrics, University of Milano-Bicocca , Milano , Italy
| | - Mariangela Arnoldi
- a Maternal and Pediatric Department , USSD Centro PMA, Ospedale Papa Giovanni XXIII , Bergamo , Italy and
| | - Chiara Bosisio
- a Maternal and Pediatric Department , USSD Centro PMA, Ospedale Papa Giovanni XXIII , Bergamo , Italy and
| | - Grazia Lombardo
- a Maternal and Pediatric Department , USSD Centro PMA, Ospedale Papa Giovanni XXIII , Bergamo , Italy and
| | - Marina Ferrario
- a Maternal and Pediatric Department , USSD Centro PMA, Ospedale Papa Giovanni XXIII , Bergamo , Italy and
| | - Laura Zanga
- a Maternal and Pediatric Department , USSD Centro PMA, Ospedale Papa Giovanni XXIII , Bergamo , Italy and
| | - Alessia Galimberti
- a Maternal and Pediatric Department , USSD Centro PMA, Ospedale Papa Giovanni XXIII , Bergamo , Italy and
| | - Enrica Capitanio
- a Maternal and Pediatric Department , USSD Centro PMA, Ospedale Papa Giovanni XXIII , Bergamo , Italy and
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Nawroth F. Additive hormonelle Therapie bei der assistierten Reproduktion. GYNAKOLOGISCHE ENDOKRINOLOGIE 2014. [DOI: 10.1007/s10304-013-0602-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Lin MH, Wu FSY, Lee RKK, Li SH, Lin SY, Hwu YM. Dual trigger with combination of gonadotropin-releasing hormone agonist and human chorionic gonadotropin significantly improves the live-birth rate for normal responders in GnRH-antagonist cycles. Fertil Steril 2013; 100:1296-302. [PMID: 23993928 DOI: 10.1016/j.fertnstert.2013.07.1976] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 07/18/2013] [Accepted: 07/18/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To investigate whether dual triggering of final oocyte maturation with a combination of gonadotropin-releasing hormone (GnRH) agonist and human chorionic gonadotropin (hCG) can improve the live-birth rate for normal responders in GnRH-antagonist in vitro fertilization/intracytoplasmic sperm injection (IVF-ICSI) cycles. DESIGN Retrospective cohort study. SETTING Infertility unit of a university-affiliated medical center. PATIENT(S) Normal responders to controlled ovarian hyperstimulation who were undergoing IVF-ICSI with a GnRH antagonist protocol. INTERVENTION(S) Standard dosage of hCG trigger (6,500 IU of recombinant hCG) versus dual trigger (0.2 mg of triptorelin and 6,500 IU of recombinant hCG). MAIN OUTCOME MEASURE(S) Live-birth, clinical pregnancy, and implantation rates per cycle. RESULT(S) A total of 376 patients with 378 completed cycles with embryo transfer were enrolled (hCG trigger/control group: n = 187; dual trigger/study group: n = 191). The dual trigger group demonstrated statistically significantly higher implantation (29.6% vs. 18.4%), clinical pregnancy (50.7% vs. 40.1%), and live-birth (41.3% vs. 30.4%) rates as compared with the hCG trigger group. There was no statistically significant difference in terms of patient demographics, cycle parameters, or embryo quality. CONCLUSION(S) Dual trigger of final oocyte maturation with a GnRH-agonist and a standard dosage of hCG in normal responders statistically significantly improves implantation, clinical pregnancy, and live-birth rates in GnRH-antagonist IVF cycles.
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Affiliation(s)
- Ming-Huei Lin
- Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei, Taiwan; Mackay Medicine, Nursing, and Management College, Taipei, Taiwan
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Inamdar DB, Majumdar A. Evaluation of the impact of gonadotropin-releasing hormone agonist as an adjuvant in luteal-phase support on IVF outcome. J Hum Reprod Sci 2013; 5:279-84. [PMID: 23532169 PMCID: PMC3604836 DOI: 10.4103/0974-1208.106341] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 07/14/2012] [Accepted: 09/14/2012] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES: To evaluate whether three daily doses of GnRH agonist (Inj. Lupride 1 mg SC) administered 6 days after oocyte retrieval increases ongoing pregnancy rates following embryo transfer (ET) in cycles stimulated with the long GnRH agonist protocol. SETTINGS AND DESIGN: Prospective randomized controlled study in a tertiary care center. MATERIALS AND METHODS: Four hundred and twenty six women undergoing ET following controlled ovarian stimulation with a long GnRH agonist protocol were included. In addition to routine luteal-phase support (LPS) with progesterone, women were randomized to receive three 1 mg doses of Lupride 6 days after oocyte retrieval. Computer-generated randomization was done on the day of ET. Ongoing pregnancy rate beyond 20th week of gestation was the primary outcome measure. The trial was powered to detect a 13% absolute increase from an assumed 27% ongoing pregnancy rate in the control group, with an alpha error level of 0.05 and a beta error level of 0.2. RESULTS: There were 59 (27.69%) ongoing pregnancies in the GnRHa group, and 56 (26.29%) in the control group (P = 0.827). Implantation, clinical pregnancy and multiple pregnancy rates were likewise similar in the GnRHa and placebo groups. CONCLUSIONS: Three 1 mg doses of Lupride administration 6 days after oocyte retrieval in the long protocol cycles does not result in an increase in ongoing pregnancy rates.
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Affiliation(s)
- Dattaprasad B Inamdar
- Department of Obstetrics and Gynecology, Fellow in Reproductive Medicine, Sir Ganga Ram Hospital, New Delhi, India
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Agonist trigger: what is the best approach? Agonist trigger with aggressive luteal support. Fertil Steril 2012; 97:531-3. [DOI: 10.1016/j.fertnstert.2011.12.020] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Revised: 12/17/2011] [Accepted: 12/19/2011] [Indexed: 11/18/2022]
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A case report: successful pregnancy after controlled ovarian hyperstimulation by using short-acting gonadotropin releasing hormone agonist only. J Assist Reprod Genet 2012; 29:329-30. [PMID: 22318292 DOI: 10.1007/s10815-012-9716-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2011] [Accepted: 01/10/2012] [Indexed: 10/14/2022] Open
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Abstract
The acute and chronic effects of certain drugs can often be opposite. For example, in congestive heart failure acute administration of β-adrenoceptor agonists results in beneficial improvement in symptoms of the disease, but their chronic use increases mortality. Conversely, certain β-adrenoceptor antagonists/inverse agonists (β-blockers) initially cause a detrimental response by decreasing cardiac contractility in congestive heart failure, whereas chronic treatment with the same β-blockers improves contractility and survival. Furthermore, this time-dependent reversal of outcomes occurs in nonpharmacological interventions, such as exercise, and can even be observed in the response of plants to pruning or other stressors, with the results being a different short-term versus long-term effect. Here, we review some of these phenomena with a special emphasis on the temporal dissociation of pharmacological effects. Although Francis Colpaert used this knowledge to lead a drug discovery project for an analgesic compound that initially produced hyperalgesia, we focused on examples outside the central nervous system.
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Beyer DA, Amari F, Thill M, Schultze-Mosgau A, Al-Hasani S, Diedrich K, Griesinger G. Emerging gonadotropin-releasing hormone agonists. Expert Opin Emerg Drugs 2011; 16:323-40. [PMID: 21244327 DOI: 10.1517/14728214.2010.547472] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Gonadotropin-releasing hormone agonist analogs (GnRHa) are peptides that mimic the action of gonadotropin-releasing hormone (GnRH) and are used to suppress subsequent sex steroid production. Although the analogs are a rather defined group of drugs, there have been developments in the past decades and there is still ample room for improvement. New therapeutic strategies in the use of GnRHs are discussed. AREAS COVERED Major points of discussion include: i) the use of concomitant treatment of early breast cancer in premenopausal estrogen-positive and -negative patients, ii) the use of GnRHa for fertility preservation in young female patients with malignant diseases and iii) the use of GnRH analogs in assisted reproduction. The manuscript provides a better understanding of GnRH agonists as well as an explanation of their major indications, biochemical pathways and concluding therapeutic strategies. Recent results from international meetings and debates are described to explain current controversies. EXPERT OPINION This paper highlights the need for more complex GnRH analogs. In the next few years, there will be longer acting GnRHas that may improve adherence. New therapeutic targets in oncological concepts may go beyond fertility preservation and focus on the antiproliferative effects of GnRH analogs.
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Affiliation(s)
- Daniel Alexander Beyer
- University of Schleswig Holstein, Department of Obstetrics and Gynaecology, Campus Lübeck, Ratzeburger Allee 160, D- 23538 Lübeck, Germany.
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