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Sokteang S, Ou P, Tran C, de Ziegler D. Programming the onset of ovarian stimulation: from early follicular phase start to oral contraceptive pill, to luteal phase E2, Duostim, and random start oral contraceptive protocols. Fertil Steril 2024:S0015-0282(24)02224-6. [PMID: 39270829 DOI: 10.1016/j.fertnstert.2024.09.011] [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: 08/13/2024] [Revised: 09/03/2024] [Accepted: 09/05/2024] [Indexed: 09/15/2024]
Abstract
Ovarian stimulation has been the single most efficient measure ever taken in assisted reproductive technology for improving outcomes by harvesting multiple oocytes and ultimately, embryos. Today, ovarian stimulation protocols consist of administrating exogenous gonadotropins to override the natural mechanisms that control the ovulatory quota to one in humans. For practicality issues, there have been numerous attempts to control, or "program," when ovarian stimulation is initiated to improve functionality and in turn efficacy for assisted reproductive technology programs. The different options for controlling the onset of ovarian stimulation currently available are discussed here, as well as the novel possibility of using progestins for blocking premature ovulation.
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Affiliation(s)
- Sean Sokteang
- Fertility Clinic of Cambodia (FCC), Phnom Penh, Cambodia
| | - Pichetra Ou
- Fertility Clinic of Cambodia (FCC), Phnom Penh, Cambodia
| | - Chloe Tran
- Fertility Clinic of Cambodia (FCC), Phnom Penh, Cambodia
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Sokteang S, Pirtea P, Toner JP, de Ziegler D. Ovarian hyperstimulation syndrome should be dead, we are just waiting on the obituary. Fertil Steril 2024; 122:230-232. [PMID: 38403105 DOI: 10.1016/j.fertnstert.2024.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/20/2024] [Indexed: 02/27/2024]
Affiliation(s)
- Sean Sokteang
- Fertility Clinic of Cambodia, Phnom Penh, Kingdom of Cambodia
| | - Paul Pirtea
- Deptartment of Obstetrics and Gynecology, Hopital Foch - Université de Paris Ouest (UVSQ), Paris, France
| | - James P Toner
- Department of Obstetrics and Gynecology, Emory University, Atlanta, Georgia
| | - Dominique de Ziegler
- Fertility Clinic of Cambodia, Phnom Penh, Kingdom of Cambodia; Deptartment of Obstetrics and Gynecology, Hopital Foch - Université de Paris Ouest (UVSQ), Paris, France.
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Guner FC, Ozekinci M, Mendilcioglu II, Kasabali Z. Reproductive Outcomes of Dual Trigger versus hCG Alone in Women Undergoing In Vitro Fertilization with Fresh Embryo Transfer Cycles. Obstet Gynecol Int 2024; 2024:9972437. [PMID: 39015476 PMCID: PMC11251794 DOI: 10.1155/2024/9972437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 06/18/2024] [Accepted: 06/27/2024] [Indexed: 07/18/2024] Open
Abstract
Aim To investigate the effect of the triggering method on the results of fresh embryo transfer in patients who underwent gonadotropin-releasing hormone antagonist cycles. Methods The study was conducted retrospectively at a university-based tertiary reproductive center. The sample consisted of a total of 295 patients, of whom 111 were in the human chorionic gonadotropin (hCG) trigger group and 184 were in the dual trigger group. The main outcome measure of this study was the live birth rate, and secondary outcomes were the implantation rate, clinical pregnancy rate, miscarriage rate, and good-quality embryo rate. Results Patient demographics and baseline characteristics did not significantly differ between the dual and hCG trigger groups. The results also indicated statistically nonsignificant differences between the two groups in terms of the number of oocytes retrieved (p > 0.05), the number of mature oocytes (p > 0.05), and the fertilization rate (p > 0.05). The number of good-quality embryos (p=0.002) was higher in the dual trigger group compared with the hCG trigger group. However, the rates of clinical pregnancy and live births did not significantly differ between the groups (p > 0.05). Conclusions Although the number of total and high-quality embryos obtained was higher in the dual trigger group, there were no significant differences between the two groups in terms of pregnancy outcomes. The fresh embryo transfer yielded similar rates of implantation and live births in both trigger groups.
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Affiliation(s)
- Fatma Ceren Guner
- Department of Obstetrics and GynecologyAkdeniz University, Antalya 07058, Türkiye
| | - Murat Ozekinci
- Department of Obstetrics and GynecologyReproductive Endocrinology and InfertilityAkdeniz University, Antalya 07058, Türkiye
| | | | - Zeliha Kasabali
- IVF UnitDepartment of Obstetrics and GynecologyAkdeniz University, Antalya 07058, Türkiye
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Petrogiannis N, Chatzovoulou K, Filippa M, Grimbizis G, Kolibianakis E, Chatzimeletiou K. In vitro maturation of oocytes in light of ovarian mitochondrial improvement: effectiveness and safety. ZYGOTE 2024:1-7. [PMID: 38953841 DOI: 10.1017/s0967199424000182] [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: 07/04/2024]
Abstract
In vitro maturation of oocytes (IVM) represents an assisted reproductive technique that involves the minimal or absence of ovarian stimulation and is beneficial to specific groups of patients. These may include women with polycystic ovarian syndrome and/or patients who need a fertility preservation option before undergoing gonadotoxic treatment. However, when IVM is applied in cases where it is not recommended, it can be considered as an add-on technique, as described by the ESHRE Guideline Group on Female Fertility Preservation. Interestingly, IVM has not been proven yet to be as effective as conventional IVF in the laboratory, in terms of clinical pregnancy and live birth rates, while concerns have been raised for its long-term safety. As a result, both safety and efficacy of IVM remain still questionable and additional data are needed to draw conclusions.
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Affiliation(s)
| | | | | | - Grigoris Grimbizis
- Unit for Human Reproduction, 1st Department of Obstetrics and Gynaecology, Aristotle University Medical School, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Efstratios Kolibianakis
- Unit for Human Reproduction, 1st Department of Obstetrics and Gynaecology, Aristotle University Medical School, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Katerina Chatzimeletiou
- Unit for Human Reproduction, 1st Department of Obstetrics and Gynaecology, Aristotle University Medical School, Papageorgiou General Hospital, Thessaloniki, Greece
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Xu K, Wang J, Yang S, Wang Z, Hou N, Sun M. Comparison of HCG Trigger versus Dual Trigger in Improving Pregnancy Outcomes in Patients with Different Ovarian Responses: A Retrospective Study. Int J Endocrinol 2024; 2024:2507026. [PMID: 38855192 PMCID: PMC11161263 DOI: 10.1155/2024/2507026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 05/10/2024] [Accepted: 05/13/2024] [Indexed: 06/11/2024] Open
Abstract
Objective During in vitro fertilization-embryo transfer (IVF-ET) treatment, the reproductive endocrine regulatory mechanisms hold pivotal importance. Specifically, the serum estradiol (E 2) level during ovulation emerges as a critical factor influencing pregnancy outcomes. This retrospective study aimed to comprehensively compare two common clinical regimens based on the grouping of serum E 2 levels and the number of oocytes retrieved on the trigger day. Our objective was to evaluate the pregnancy outcomes in IVF-ET patients across different ovarian response groups, exploring the efficacy of the dual-trigger and single-trigger regimens to provide valuable insights for optimizing clinical strategies in the context of IVF-ET. Methods A retrospective analysis was conducted on the clinical data of 2778 infertile patients who underwent ART (IVF/ICSI). Subsequently, a detailed statistical analysis was performed on 1032 patients following an antagonist regimen. Participants were categorized into single-trigger and dual-trigger groups based on real-world trigger protocols, considering different ovarian responses. Comprehensive statistical assessments were conducted on baseline characteristics, ovulation induction, and pregnancy outcomes. Results Baseline characteristics and cycle parameters among the three patient groups (high ovarian response, normal response, and poor response) exhibited no significant differences between the dual-trigger and single-trigger regimen groups. Despite the dual-trigger regimen utilizing a significantly lower HCG dose, no notable discrepancies were observed in laboratory results and pregnancy outcomes (embryo transfer rate, pregnancy rate, and live birth rate) for normal and high responders. Remarkably, E 2 levels were higher in the dual-trigger group compared to the single-trigger group. In high and normal responders, the dual-trigger regimen demonstrated increased oocyte counts and oocyte acquisition rates, coupled with decreased transfer cancellation rates attributed to ovarian hyperstimulation syndrome (OHSS). Intriguingly, patients with a poor ovarian response experienced no graft cancellations due to OHSS prevention in either group. Conclusion For patients with high and normal ovarian responses, the utilization of a dual-trigger regimen on the trigger day effectively mitigates the risk of OHSS. Our large sample study supports the substitutability of the dual-trigger regimen over the single-trigger regimen without compromising pregnancy outcomes. However, this conclusion is not applicable to patients with poor ovarian responses. The results of this study highlight the necessity of adopting a customized and individualized treatment approach that should be based on the patient's ovarian response. Additionally, recognizing the pivotal role of the endocrine environment in influencing pregnancy outcomes and the occurrence of OHSS, further exploration of the effects of different triggering regimens on endocrine parameters is warranted. Such investigations will contribute to enhancing the reproductive outcomes of IVF-ET technology.
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Affiliation(s)
- Ke Xu
- Center for Reproductive Medicine, Shandong University, Jinan 250012, Shandong, China
- Key Laboratory of Reproductive Endocrinology of Ministry of Education, Shandong University, Jinan 250012, Shandong, China
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250012, China
- National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Shandong University, Jinan 250012, Shandong, China
| | - Jinrong Wang
- Center for Reproductive Medicine, Shandong University, Jinan 250012, Shandong, China
- Department of Pharmacology, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China
| | - Shuangshuang Yang
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250012, China
- Shandong First Medical University (Shandong Academy of Medical Sciences), Jinan 250117, Shandong, China
| | - Zhenjing Wang
- Center for Reproductive Medicine, Shandong University, Jinan 250012, Shandong, China
- Key Laboratory of Reproductive Endocrinology of Ministry of Education, Shandong University, Jinan 250012, Shandong, China
- National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Shandong University, Jinan 250012, Shandong, China
| | - Ning Hou
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250012, China
| | - Mei Sun
- Center for Reproductive Medicine, Shandong University, Jinan 250012, Shandong, China
- Key Laboratory of Reproductive Endocrinology of Ministry of Education, Shandong University, Jinan 250012, Shandong, China
- National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Shandong University, Jinan 250012, Shandong, China
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Boudry L, Mateizel I, Wouters K, Papaleo E, Mackens S, De Vos M, Racca A, Adriaenssens T, Tournaye H, Blockeel C. Does dual oocyte retrieval with continuous FSH administration increase the number of mature oocytes in low responders? An open-label randomized controlled trial. Hum Reprod 2024; 39:538-547. [PMID: 38199789 DOI: 10.1093/humrep/dead276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 11/21/2023] [Indexed: 01/12/2024] Open
Abstract
STUDY QUESTION Is there an increase in the total number of metaphase II (MII) oocytes between a conventional ovarian stimulation (OS) and a double uninterrupted stimulation? SUMMARY ANSWER There is no increase in the total number of MII oocytes when comparing one conventional OS to a continuous stimulation with double oocyte aspiration. WHAT IS KNOWN ALREADY Based on the concept of multiple follicular waves, the combination of two stimulations in the same ovarian cycle has gained interest in patients with a low ovarian reserve. This so-called dual stimulation approach is usually characterized by a discontinuation of FSH administration for ∼5 days and appears to have a favourable impact on the number of retrieved oocytes without affecting the embryo quality or ploidy status. The outcomes of dual uninterrupted OS have not yet been studied. STUDY DESIGN, SIZE, DURATION This was an open-label randomized controlled trial (RCT) with superiority design, performed in a single tertiary centre. Subjects were randomized with a 1:1 allocation into two groups between October 2019 and September 2021. All patients underwent a conventional stimulation with recombinant FSH. When two or more follicles of 17 mm were present, the final inclusion criterion was assessed; randomization occurred only in the presence of ≤9 follicles of ≥11 mm. In Group A, ovulation was triggered with hCG, and oocyte retrieval (OR) was performed 34-36 h later, followed by a fresh single or double embryo transfer (SET or DET) on Day 3/5. In Group B, ovulation was triggered with GnRH agonist, followed by another OS, without discontinuation of the FSH administration. In the presence of one or more follicles of ≥17 mm, the second stimulation was completed with hCG. A freeze-all strategy (Day 3/5) was applied for both retrievals, followed by transfer of one or two embryos in an artificially prepared frozen-thawed cycle. In the absence of one or more follicles of ≥17 mm after 13 additional days of stimulation, the second cycle was cancelled. All ORs were executed by a senior fertility specialist who was blinded for the first treatment, and all follicles >10 mm were aspirated, according to routine clinical practice. The primary outcome was the total number of MII oocytes. Patients were followed up until all embryos were transferred, or until live birth was achieved. Other secondary outcomes included the number of cumulus-oocyte complexes (COCs), the number of good quality embryos (Day 3/5), the ongoing pregnancy rate, and gonadotropin consumption. PARTICIPANTS/MATERIALS, SETTING, METHODS Patients between 25 and 40 years old, with an anti-Müllerian hormone level of ≤1.5 ng/ml, antral follicle count of ≤6, or ≤5 oocytes after a previous stimulation, were included. At the start, 70 patients were eligible for participation in the trial, of whom 48 patients fulfilled the final inclusion criterium and were randomized. After drop-out of two patients, 23 patients were randomized to a single round of OS (Group A), and 23 patients were randomized to two uninterrupted rounds of OS (Group B). MAIN RESULTS AND THE ROLE OF CHANCE Baseline characteristics were similar between both groups. The cumulative number of COCs and MII oocytes after completion of the second OR was similar in Group A and Group B [5.3 ± 2.7 versus 5.3 ± 3.0 (P = 0.95); 4.1 ± 2.4 versus 4.3 ± 2.7 (P = 0.77)]. Likewise, a comparable number of excellent and good quality embryos was available on Day 3 (3.0 ± 2.0 versus 2.7 ± 2.0; P = 0.63). In Group B, the cancellation rate due to insufficient response to the second round of stimulation was 39.1% (9/23). When focusing on the first stimulation in both groups, there were no significant differences regarding basal FSH, gonadotropin consumption, and the number of preovulatory follicles. After the first OR, the mean number of COC and MII oocytes was significantly higher in Group A (who had hCG triggering), compared to Group B (who had GnRH agonist triggering) [5.3 ± 2.7 versus 3.3 ± 2.2; difference 95% CI (0.54 to 3.45), P = 0.004 and 4.1 ± 2.4 versus 3.0 ± 2.2; difference 95% CI (-0.15 to 2.6), P = 0.05, respectively]. Likewise, the number of excellent and good quality embryos on Day 3 was significantly higher (3.0 ± 2.0 versus 1.9 ± 1.7; P = 0.02) in Group A. LIMITATIONS, REASONS FOR CAUTION This study was powered to demonstrate superiority for the number of MII oocytes after dual stimulation. Investigating the impact of dual stimulation on pregnancy rates would have required a larger sample size. Furthermore, the heterogeneity in embryo vitrification and transfer policies precluded a correct comparison of embryologic outcomes between both groups. WIDER IMPLICATIONS OF THE FINDINGS This is the first RCT investigating the role of continuous stimulation with double aspiration in low responders. Our results show no statistically significant differences in the cumulative number of MII oocytes between one conventional stimulation with fresh ET and two consecutive stimulations with a freeze-only approach. Furthermore, the observed suboptimal oocyte yield after agonist ovulation triggering in low responders in the dual uninterrupted OS group is a reason for concern and further scrutiny, given that previous RCTs have shown similar outcomes in normal and high responders after hCG and GnRH agonist triggers. STUDY FUNDING/COMPETING INTEREST(S) This work was supported in part by a research grant from Organon. H.T. received honoraria for lectures and presentations from Abbott, Cooper Surgical, Gedeon-Richter, Cook, Goodlife, and Ferring. L.B. received fees for lectures from Merck & Organon and support for attending ESHRE 2023. M.D.V. reports fees for lectures from Ferring, Merck, Organon, IBSA, Gedeon Richter, and Cooper Surgical and support for attending ASRM 2023. S.M. received honoraria for lectures and presentations from Abbott, Cooper Surgical, Gedeon-Richter, IBSA, and Merck. C.B. was on the Advisory board and received consulting fees from Theramex and received honoraria for lectures and presentations from Abbott, Ferring, Gedeon-Richter, IBSA, and Merck. TRIAL REGISTRATION NUMBER NCT03846544. TRIAL REGISTRATION DATE 19 February 2019. DATE OF FIRST PATIENT’S ENROLMENT 28 October 2019.
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Affiliation(s)
- L Boudry
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - I Mateizel
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - K Wouters
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - E Papaleo
- Obstetrics and Gynaecology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - S Mackens
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - M De Vos
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - A Racca
- Department of Gynaecology and Reproductive Medicine, Instituto Bernabeu Venezia, Venezia, Italy
| | - T Adriaenssens
- Laboratory of Follicle Biology, Vrije Universiteit Brussel, Brussels, Belgium
| | - H Tournaye
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - C Blockeel
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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Keskin M, Ecemiş T, Atik A, Yeğen P, Kalkan E, Yücel GS. Cycle outcomes of dual trigger (GnRH agonist+hCG) versus human chorionic gonadotropin trigger alone in POSEDION group 3-4 poor-responders and normo-responders: A prospective randomized study. J Gynecol Obstet Hum Reprod 2023; 52:102633. [PMID: 37487959 DOI: 10.1016/j.jogoh.2023.102633] [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: 01/27/2023] [Revised: 06/11/2023] [Accepted: 07/20/2023] [Indexed: 07/26/2023]
Abstract
INTRODUCTION Recently, dual trigger was proposed in an attempt to improve in vitro fertilization (IVF) cycle outcomes in poor and normo-responder patients (PR and NR, respectively). The study's aim was to compare cycle outcomes of dual trigger versus human chorionic gonadotropin (hCG) trigger in NRs and POSEIDON group 3/4 (PG 3/4) PRs. MATERIAL AND METHODS A prospective randomized controlled trial included PG 3/4 PRs and NRs undergoing IVF using a gonadotropin-releasing hormone (GnRH) antagonist protocol. PRs and NRs were divided into two subgroups: (1) study groups in both arms received dual trigger and (2) control groups received only HCG. RESULTS Two-hundred twenty-five women participated in the study. The mean patient age was significantly higher in the dual trigger group versus the HCG trigger group in PG 3/4 PRs. The number of retrieved oocytes and MII oocytes and the number of patients with good quality embryos were comparable between groups and live birth rates (LBR) per embryo transfer (ET) were significantly higher in the HCG group versus the dual trigger group in PG3/4 PRs (39.2% versus 19.2%; p = 0.026). NR dual trigger and HCG trigger groups were comparable in terms of patient age and LBR per ET did not significantly differ between these groups. The number of patients with good quality embryos was significantly higher in the dual trigger group versus the HCG group in NRs CONCLUSION: Dual trigger does not seem to add additional benefits in terms of live birth rates in PG3/4 PRs and NRs. Nonetheless, considering the age difference and lack of homogenity in the number and day of embryos transferred in PG 3/4 PRs, major conclusion that can be drawn from the study is that dual trigger is not systematically useful even in poor responders since the number of mature oocytes is comparable between groups. Larger scale studies are required for additional potential implications.
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Affiliation(s)
- Müge Keskin
- Department of Obstetrics and Gynecology, Ufuk University Faculty Of Medicine, Kızılırmak, Ufuk Ünv. Cd No:1 Çankaya, Ankara 06510, Turkey.
| | | | | | - Pelin Yeğen
- General Practitioner Service, Prof. Dr. Süleyman Yalçın Hospital, İstanbul, Turkey
| | - Ece Kalkan
- General Practitioner Service, Ankara Research and Training Hospital, Turkey
| | - Gamze Sinem Yücel
- Department of Obstetrics and Gynecology, Ufuk University Faculty Of Medicine, Kızılırmak, Ufuk Ünv. Cd No:1 Çankaya, Ankara 06510, Turkey
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He FF, Hu W, Yong L, Li YM. Triggering of ovulation for GnRH-antagonist cycles in normal and low ovarian responders undergoing IVF/ICSI: A systematic review and meta-analysis of randomized trials. Eur J Obstet Gynecol Reprod Biol 2023; 289:65-73. [PMID: 37639817 DOI: 10.1016/j.ejogrb.2023.08.014] [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: 02/24/2023] [Revised: 06/01/2023] [Accepted: 08/15/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVE To conduct a systematic review andmeta-analysis of all randomized controlled trials (RCTs) that investigated whether dual triggering [a combination of gonadotropin-releasing hormone (GnRH) agonist and human chorionic gonadotropin (hCG)] of final oocyte maturation can improve the number of oocytes retrieved and clinical pregnancy rate in low or normal responders undergoing in-vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) cycles using a GnRH-antagonist protocol. STUDY DESIGN Studies up to October 2022 were identified from PubMed, Scopus, Cochrane Library and Web of Science. The risk of bias of included studies was assessed. Dichotomous outcomes were reported as relative risks (RR), and continuous outcomes were reported as weighted mean differences (WMD) with 95% confidence intervals (CI). The primary outcomes were number of oocytes retrieved, number of mature [metaphase II (MII)] oocytes, clinical pregnancy rate and ongoing pregnancy rate; other IVF outcomes were considered as secondary outcomes. RESULTS Seven studies were identified, and 898 patients were eligible for inclusion in this meta-analysis. The results showed that the number of oocytes retrieved [WMD = 1.38 (95% CI 0.47-2.28), I2 = 66%, p = 0.003, low evidence], number of MII oocytes [WMD = 0.7 (95% CI 0.35-1.05), I2 = 42%, p < 0.0001, moderate evidence], number of embryos [WMD = 0.68 (95% CI 0.07-1.3), I2 = 67%, p = 0.03, low evidence] and number of good-quality embryos [WMD = 1.14 (95% CI 0.35-1.93), I2 = 0%, p = 0.005, moderate evidence] in the dual trigger group were significantly higher than in the hCG trigger group. The results of the ovarian response subgroup analysis showed significant differences in all of these outcomes in normal responders, and no differences in any of the outcomes in low responders, except for the number of MII oocytes. In low responders, clinical pregnancy rates may be improved in the dual trigger group [RR = 2.2 (95% CI 1.05-4.61), I2 = 28%, p = 0.04, low evidence]. CONCLUSION Dual triggering by GnRH agonist and hCG improved oocyte maturity and embryo grading for normal responders in GnRH-antagonist cycles. Dual triggering for final oocyte maturation may improve clinical pregnancy rates in low responders.
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Affiliation(s)
- Fang-Fang He
- Reproductive Center of Chengdu Jinjiang District Maternal and Child Health Hospital, Chengdu, People's Republic of China
| | - Wenhui Hu
- Reproductive Center of Chengdu Jinjiang District Maternal and Child Health Hospital, Chengdu, People's Republic of China
| | - Lin Yong
- Reproductive Center of Chengdu Jinjiang District Maternal and Child Health Hospital, Chengdu, People's Republic of China
| | - Yu-Mei Li
- Department of Assisted Reproduction, Xiangya Hospital, Central South University, Changsha, People's Republic of China.
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Cevher Akdulum MF, Arık Sİ, Demirdağ E, Erdem M, Erdem A. In Vitro Fertilization Outcomes With a Dual Trigger in Normoresponders in Antagonist Cycles. Cureus 2023; 15:e45623. [PMID: 37868584 PMCID: PMC10588958 DOI: 10.7759/cureus.45623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 10/24/2023] Open
Abstract
Objectives To evaluate whether the dual trigger of ovulation with a gonadotropin-releasing hormone (GnRH) agonist and the standard dose of recombinant human chorionic gonadotropin (hCG) (dual trigger) is better than hCG alone in in vitro fertilization (IVF) cycles of patients who responded well to ovarian stimulation. Methods Between January 2013 and December 2021, 5593 antagonist cycles of patients were reviewed. This study included women who had an antral follicle count of 5 or more and exhibited a normoresponse to ovarian stimulation using the GnRH antagonist protocol, as determined by the follicular output rate (FORT). The primary outcome indicators consisted of the quantities of retrieved oocytes and mature oocytes. The secondary outcome markers included live birth rates, clinical pregnancy rates, and continued pregnancy rates. Results A total of 1244 normoresponder women who met the inclusion criteria were identified from the scanned files and subsequently enrolled in the GnRH antagonist protocol. A total of 383 cycles were observed in the group that was given the standard hCG trigger while 861 cycles were observed in the group that was given the dual trigger. The number of mature oocytes and top-quality embryos was significantly higher in the dual trigger group. The maturation rate in the hCG group was 74.8% while it was 76.9% in the dual trigger group (p=0.018). The dual trigger group exhibited an ongoing pregnancy rate of 37.6%, whereas the hCG group had a rate of 30.1% (p = 0.02). The dual trigger group exhibited a slightly higher live birth rate (34.3% vs 29.2%, p = 0.11), although this difference did not reach statistical significance. Conclusion Dual trigger of ovulation was superior to hCG alone in terms of the number of mature oocytes yielded, top quality of embryos, maturation rates, and ongoing pregnancy in IVF cycles of normoresponders having ovarian stimulation on the GnRH antagonist protocol.
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Affiliation(s)
| | | | - Erhan Demirdağ
- Obstetrics and Gynecology, Gazi University, School of Medicine, Ankara, TUR
| | - Mehmet Erdem
- Obstetrics and Gynaecology, Gazi University, Ankara, TUR
| | - Ahmet Erdem
- Obstetrics and Gynecology, Gazi University, Ankara, TUR
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Humaidan P, Haahr T. GnRHa trigger-the story of the ugly duckling. F S Rep 2023; 4:15-19. [PMID: 37223771 PMCID: PMC10201294 DOI: 10.1016/j.xfre.2023.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 12/07/2022] [Accepted: 02/22/2023] [Indexed: 03/03/2023] Open
Abstract
The objective of this invited review is to describe the introduction and development of the GnRH agonist (GnRHa) trigger protocol in modern in vitro fertilization, focusing on ovarian hyperstimulation syndrome (OHSS) prevention and, equally important on the role of GnRHa trigger as an opener of the luteal phase "black box." The GnRHa trigger and freezing of all embryos is the ultimate weapon against OHSS in the OHSS-risk patient. In the non OHSS-risk patient, GnRHa trigger followed by a modified luteal phase support with lutein hormone activity and subsequent fresh embryo transfer results in excellent reproductive outcomes. Thus, the GnRHa trigger has paved the way for a virtually OHSS-free clinic, and equally important is the fact that the early lessons learned from studying the GnRHa trigger opened the "black box" of the luteal phase enabling improved reproductive outcomes in both fresh and frozen embryo transfer cycles.
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Affiliation(s)
- Peter Humaidan
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Fertility Clinic Skive, Skive Regional Hospital, Skive, Denmark
| | - Thor Haahr
- Fertility Clinic Skive, Skive Regional Hospital, Skive, Denmark
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
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11
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Acosta-Martínez M. Hypothalamic-Pituitary-Gonadal Axis Disorders Impacting Fertility in Both Sexes and the Potential of Kisspeptin-Based Therapies to Treat Them. Handb Exp Pharmacol 2023; 282:259-288. [PMID: 37439848 DOI: 10.1007/164_2023_666] [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: 07/14/2023]
Abstract
Impaired function of the hypothalamic-pituitary-gonadal (HPG) axis can lead to a vast array of reproductive disorders some of which are inherited or acquired, but many are of unknown etiology. Among the clinical consequences of HPG impairment, infertility is quite common. According to the latest report from the World Health Organization, the global prevalence of infertility during a person's lifetime is a staggering 17.5% which translate into 1 out of every 6 people experiencing it. In both sexes, infertility is associated with adverse health events, and if unresolved, infertility can cause substantial psychological stress, social stigmatization, and economic strain. Even though significant advances have been made in the management and treatment of infertility, low or variable efficacy of treatments and medication adverse effects still pose a significant problem. However, the discovery that in humans inactivating mutations in the gene encoding the kisspeptin receptor (Kiss1R) results in pubertal failure and infertility has expanded our understanding of the mechanisms underlying the neuroendocrine control of reproduction, opening up potential new therapies for the treatment of infertility disorders. In this chapter we provide an overview of common infertility disorders affecting men and women, their recommended treatments, and the potential of kisspeptin-based pharmacotherapies to treat them.
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Affiliation(s)
- Maricedes Acosta-Martínez
- Department of Physiology and Biophysics, Renaissance School of Medicine at Stony Brook, Stony Brook, NY, USA.
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12
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Dong L, Lian F, Wu H, Xiang S, Li Y, Wei C, Yu X, Xin X. Reproductive outcomes of dual trigger with combination GnRH agonist and hCG versus trigger with hCG alone in women undergoing IVF/ICSI cycles: a retrospective cohort study with propensity score matching. BMC Pregnancy Childbirth 2022; 22:583. [PMID: 35869444 PMCID: PMC9308204 DOI: 10.1186/s12884-022-04899-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 07/04/2022] [Indexed: 11/10/2022] Open
Abstract
Background Despite a large number of studies on the selection of trigger drugs, it remains unclear whether the dual trigger with human chorionic gonadotropin (hCG) and gonadotropin-releasing hormone (GnRH) agonist, compared to the trigger with hCG alone, can improve the reproductive outcome of patients undergoing assisted reproductive technology. Therefore, this study aimed to compare the laboratory and clinical outcomes of dual trigger versus single trigger. Methods In this retrospective cohort study, we evaluated 520 in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) cycles between July 2014 and September 2020 at the Reproductive and Genetic Center of Integrative Medicine, The Affiliated Hospital of Shandong University of Traditional Chinese Medicine. All patients underwent IVF/ICSI treatment with fresh embryo transfer using the GnRH antagonist protocol. We used propensity score matching to control for confounding variables and binary logistic regression analysis to determine the correlations between trigger methods and pregnancy outcomes. After propensity score matching, 57 cycles from each group were evaluated and compared for laboratory or clinical outcomes in this retrospective cohort study. Results There was no significant difference in the number of oocytes retrieved, embryos available, top-quality embryos, or the rate of normal fertilization between the dual-trigger and single-trigger protocols, respectively. The incidence of ovarian hyperstimulation syndrome, implantation rate, biochemical pregnancy rate, clinical pregnancy rate, ectopic pregnancy rate, early miscarriage rate, and live birth rate were also similar between the two groups, while the miscarriage rate (37.0% vs. 12.5%, p = 0.045) was higher in the dual-trigger than the single-trigger group. Subsequent binary logistic regression analysis showed that age was a remarkably significant independent predictor of both clinical pregnancy rate (odds ratio = 0.90, 95% confidence interval: 0.84–0.97, p = 0.006) and live birth rate (odds ratio = 0.89, 95% confidence interval: 0.82–0.97, p = 0.005). Conclusions Therefore, dual-trigger for final oocyte maturation might increase miscarriage rate, but in terms of the laboratory and other pregnancy outcomes such as clinical pregnancy rate, early miscarriage rate or live birth rate, there was no evidence to show that dual trigger was superior to an hCG-trigger alone for patients undergoing GnRH-antagonist cycles with fresh embryo transfer. Trial registration Retrospectively registered.
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13
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ELhelw EM, El Serour AGEA, Rady MS, Abdeltawab A. Freeze-all policy versus luteal phase support with low dose of human chorionic gonadotrophin for high-responder patients undergoing intracytoplasmic sperm injection on pregnancy outcomes: a retrospective cohort observational study. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2022. [DOI: 10.1186/s43043-022-00113-7] [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
The literature has always controversies on the use of freeze-all policy in high-responder women performing intracytoplasmic sperm injection. In this article, we discuss the benefits of freeze-all policy on the incidence of pregnancy outcomes and the complications.
The main body of abstract
Freeze-all policy is applied to the intracytoplasmic sperm injection program by freezing of all embryos and delaying embryo transfer to another subsequent ovarian cycle, to decrease the incidence of ovarian hyperstimulation syndrome, especially in high-responder women. Unfortunately, freeze-all policy is correlated with an increase in the economic costs and more ICSI laboratory effort. Delayed embryo transfer (ET) is correlated with more anxiety among the patients. An alternative strategy is to perform fresh embryo transfer with more intensive luteal phase support to compensate for the negative effect of the GnRH agonist on the endometrial receptivity and luteal phase support.
Short conclusion
The freeze-all policy had better pregnancy rates with less incidence of moderate to severe hyperstimulation syndrome compared with original fresh embryo transfer in high-responder women performing intracytoplasmic sperm injection.
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14
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Li D, Hu Z, Chen Q, Chai W, Cai R, Kuang Y, Lu X. Neonatal outcomes and congenital malformations in children born after progestin-primed ovarian stimulation protocol. Front Endocrinol (Lausanne) 2022; 13:965863. [PMID: 36440198 PMCID: PMC9681814 DOI: 10.3389/fendo.2022.965863] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022] Open
Abstract
Purpose The purpose of this study is to assess the safety of progestin-primed ovarian stimulation (PPOS) protocol regarding the neonatal outcomes and congenital malformations in babies born after in vitro fertilization (IVF) and frozen embryo transfer (FET). Methods In this large retrospective cohort study, a total of 16,493 infants born between 1 September 2013 and 31 July 2021 from IVF and FET cycles after treatment with either PPOS (n = 15,245) or gonadotropin-releasing hormone antagonist (GnRH-ant) (n = 1,248) were finally enrolled. The primary outcome measure was the incidence of congenital malformations. The secondary outcome measures were rates of low birth weight (LBW), very low birth weight (VLBW), preterm birth (PTB), very preterm birth (VPTB), and early neonatal death. Results Birth characteristics for both singletons and twins regarding the sex of infants, gestational age, birth weight, and birth length were comparable between the PPOS group and the GnRH-ant group. Rates of LBW, VLBW, PTB, VPTB, and early neonatal death were also similar. The reanalysis using propensity score matching (PSM) and multivariable logistic regression indicated that the PPOS protocol could not increase the risk of adverse neonatal outcomes compared with the GnRH-ant protocol. Furthermore, no significant difference was observed in the overall incidence of congenital malformations in live-born babies. After PSM and controlling for all confounders, the results remained insignificant with an adjusted odds ratio of 0.66 [95% confidence interval (CI) 0.32-1.34] and 2.43 [95% CI 0.97-6.06], respectively, for singletons and twins. Conclusions Our study suggests that compared with GnRH-ant treatment for IVF, the PPOS protocol could not produce a negative effect on the newborn population in terms of neonatal outcomes and congenital malformations.
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Affiliation(s)
| | | | | | | | - Renfei Cai
- Department of Assisted Reproduction, Shanghai Ninth People’s Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yanping Kuang
- Department of Assisted Reproduction, Shanghai Ninth People’s Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xuefeng Lu
- Department of Assisted Reproduction, Shanghai Ninth People’s Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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15
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Rahav Koren R, Miller N, Moran R, Decter D, Berkowitz A, Haikin Herzberger E, Wiser A. GnRH agonist-triggering ovulation in women with advanced age. Sci Rep 2022; 12:16401. [PMID: 36180515 PMCID: PMC9525572 DOI: 10.1038/s41598-022-20619-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 09/15/2022] [Indexed: 11/09/2022] Open
Abstract
This study evaluates the effect of GnRH agonist (GnRHa) trigger for ovulation induction among women with advanced maternal age (AMA). This is a retrospective study performed at a single assisted reproductive technology centre, 2012 to 2020. A total of 306 patients with 515 IVF cycles who were triggered with GnRHa for Ovum Pick Up (OPU), were divided into two groups according to maternal age: age ≥ 40 and age < 40. The groups were compared for demographics, stimulation parameters of IVF treatment and IVF treatment outcomes. The patients in the age < 40 group were approximately 10 years younger than the patients in the age ≥ 40 group (31 ± 5.4 vs. 41.5 ± 1.3 years, p < 0.001). The age ≥ 40 group had significantly higher mean E2/retrieved oocytes ratio, compared to the age < 40 group (310.3 ± 200.6 pg/ml vs. 239 ± 168.2 pg/ml, p = 0.003), and a lower mean MII/retrieved oocyte (35 ± 37.8 vs. 43.4 ± 35.9, p = 0.05, respectively). Multivariable logistic regression analysis for E2/retrieved oocytes demonstrated that age < 40 and total dose of gonadotropins were significant variables. In conclusion, GnRHa for ovulation triggering in high responder patients prior to OPU appears to be a good option for AMA. However, this population is characterized by different parameters of ovarian response that require further evaluation.
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Affiliation(s)
- Roni Rahav Koren
- IVF Unit, Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tchernichovsky St., 4428164, Kfar Saba, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel.
| | - Netanella Miller
- IVF Unit, Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tchernichovsky St., 4428164, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel
| | - Rimon Moran
- IVF Unit, Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tchernichovsky St., 4428164, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel
| | - Dean Decter
- IVF Unit, Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tchernichovsky St., 4428164, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel
| | - Arie Berkowitz
- IVF Unit, Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tchernichovsky St., 4428164, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel
| | - Einat Haikin Herzberger
- IVF Unit, Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tchernichovsky St., 4428164, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel
| | - Amir Wiser
- IVF Unit, Department of Obstetrics and Gynecology, Meir Medical Center, 59 Tchernichovsky St., 4428164, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel
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16
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Wickramasuriya N, Hawkins R, Atwood C, Butler T. The roles of GnRH in the human central nervous system. Horm Behav 2022; 145:105230. [PMID: 35809386 PMCID: PMC9990468 DOI: 10.1016/j.yhbeh.2022.105230] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 06/20/2022] [Accepted: 06/21/2022] [Indexed: 11/04/2022]
Abstract
It is widely known that GnRH plays a role in facilitating reproductive function via the HPG axis, and this was once believed to be its only function. However, over the last several decades important neuromodulatory roles of GnRH in multiple brain functions have been elucidated. Multiple GnRH isoforms and receptors have been detected outside the HPG-axis across different species. In this review, we focus on the human CNS where GnRH I and II isoforms and a functional GnRH I receptor have been isolated. We first describe the traditional understanding of GnRH within the hypothalamus and the pituitary and current clinical use of GnRH analogues. We then review the location and function of GnRH-producing neurons and receptors located outside the HPG axis. We next review the GnRH I and II neuron location and quantity and GnRH I receptor gene expression throughout the human brain, using the Allen Brain Map Atlas. This analysis demonstrates a wide expression of GnRH throughout the brain, including prominent expression in the basal forebrain and cerebellum. Lastly, we examine the potential role of GnRH in aging and inflammation and its therapeutic potential for neurodegenerative disease and spinal cord lesions.
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Affiliation(s)
- Nimmi Wickramasuriya
- Weill Cornell Medicine, Department of Radiology, 1305 York Ave #3F, New York, NY 1002, USA
| | - Robert Hawkins
- Weill Cornell Medicine, Department of Radiology, 1305 York Ave #3F, New York, NY 1002, USA
| | - Craig Atwood
- University of Wisconsin, Department of Medicine, 2500 Overlook Tce, Madison, WI 53705, USA
| | - Tracy Butler
- Weill Cornell Medicine, Department of Radiology, 1305 York Ave #3F, New York, NY 1002, USA.
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17
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Anaya Y, Cakmak H, Mata DA, Letourneau J, Zhang L, Lenhart N, Juarez-Hernandez F, Jalalian L, Cedars MI, Rosen M. Triggering with 1,500 IU of human chorionic gonadotropin plus follicle-stimulating hormone compared to a standard human chorionic gonadotropin trigger dose for oocyte competence in in vitro fertilization cycles: a randomized, double-blinded, controlled noninferiority trial. Fertil Steril 2022; 118:266-278. [PMID: 35705380 DOI: 10.1016/j.fertnstert.2022.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 04/29/2022] [Accepted: 05/03/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess if triggering with 1,500 IU of human chorionic gonadotropin (hCG) with 450 IU of follicle-stimulating hormone (FSH) induces noninferior oocyte competence to a standard dose of hCG trigger used in in vitro fertilization (IVF). The alternative trigger will be considered noninferior if it is at least 80% effective in promoting oocyte competence. DESIGN Randomized, double-blinded, controlled noninferiority trial. SETTING Academic infertility practice. PATIENTS Women aged 18-41 undergoing IVF with antral follicle count ≥8, body mass index ≤30 kg/m2, and no history of ≥2 IVF cycles canceled for poor response were enrolled. Participants with a serum estradiol >5,000 pg/mL on the day of trigger were excluded because of high risk of ovarian hyperstimulation syndrome. INTERVENTIONS Participants were randomized to receive an alternative trigger of 1,500 IU of hCG plus 450 IU of FSH or a standard trigger dose of hCG (5,000 or 10,000 IU) for final oocyte maturation. MAIN OUTCOME MEASURES The primary outcome was total competent proportion, defined as the probability of 2 pronuclei from an oocyte retrieved. The alternative trigger will be considered noninferior to the standard trigger if a 1-sided 95% confidence interval (CI) of the relative risk (RR) is not <0.8. Secondary outcomes included oocyte recovery and maturity, intracytoplasmic sperm injection fertilization, embryo quality, pregnancy rates, as well as serum and follicular hormones. Secondary outcomes were compared using a 2-sided superiority test. Outcomes were analyzed by intention-to-treat and per-protocol. RESULTS A total of 105 women undergoing IVF were randomized from May 2015 to June 2018. The probability of the primary outcome was 0.59 with the alternative trigger and 0.65 with the standard trigger, with a RR of 0.91 and a 1-sided 95% CI of 0.83. Noninferiority of the alternative trigger was demonstrated. Live birthrate from all fresh transfers in the alternative trigger group vs. standard trigger was 46.9 vs. 46.4% (RR, 1.01; 95% CI, 0.62-1.62), respectively. Live birthrate per randomized participant was 48.1% in the alternative trigger group vs. 62.7% with the standard trigger (RR, 0.73; 95% CI, 0.48-1.11). No participants had a failed retrieval. CONCLUSION Triggering with 1,500 IU of hCG plus 450 IU of FSH promoted noninferior oocyte competence compared to a standard hCG trigger dose. TRIAL REGISTRATION NCT02310919.
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Affiliation(s)
- Yanett Anaya
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California.
| | - Hakan Cakmak
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California
| | - Douglas A Mata
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joseph Letourneau
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California; Division of Reproductive Endocrinology and Infertility, Utah Center for Reproductive Medicine, University of Utah, Salt Lake City, Utah
| | - Li Zhang
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Nikolaus Lenhart
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California
| | - Flor Juarez-Hernandez
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California
| | - Liza Jalalian
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California
| | - Marcelle I Cedars
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California
| | - Mitchell Rosen
- Division of Reproductive Endocrinology and Infertility, Center for Reproductive Health, University of California San Francisco, San Francisco, California
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18
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He Y, Tang Y, Chen S, Liu J, Liu H. Effect of GnRH agonist alone or combined with different low-dose hCG on cumulative live birth rate for high responders in GnRH antagonist cycles: a retrospective study. BMC Pregnancy Childbirth 2022; 22:172. [PMID: 35236312 PMCID: PMC8892730 DOI: 10.1186/s12884-022-04499-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 02/21/2022] [Indexed: 11/23/2022] Open
Abstract
Background There is insufficient evidence regarding the impact of dual trigger on oocyte maturity and reproductive outcomes in high responders. Thus, we aimed to explore the effect of gonadotropin-releasing hormone agonist (GnRHa) trigger alone or combined with different low-dose human chorionic gonadotropin (hCG) regimens on rates of oocyte maturation and cumulative live birth in high responders who underwent a freeze-all strategy in GnRH antagonist cycles. Methods A total of 1343 cycles were divided into three groups according to different trigger protocols: group A received GnRHa 0.2 mg (n = 577), group B received GnRHa 0.2 mg and hCG 1000 IU (n = 403), and group C received GnRHa 0.2 mg and hCG 2000 IU (n = 363). Results There were no significant differences in age, body mass index, and rates of oocyte maturation, fertilization, available embryo, and top-quality embryo among the groups. However, the incidence of moderate to severe ovarian hyperstimulation syndrome (OHSS) was significantly different among the three groups (0% in group A, 1.49% in group B, and 1.38% in group C). For the first frozen embryo transfer (FET) cycle, there were no significant differences in the number of transferred embryos and rates of implantation, clinical pregnancy, live birth, and early miscarriage among the three groups. Additionally, the cumulative ongoing pregnancy rate and cumulative live birth rate were not significantly different among the three groups. Similarly, there were no significant differences in gestational age, birth weight, birth height, and the proportion of low birth weight among subgroups stratified by singleton or twin. Conclusions GnRHa trigger combined with low-dose hCG (1000 IU or 2000 IU) did not improve oocyte maturity and embryo quality and was still associated with an increased risk of moderate to severe OHSS. Therefore, for high responders treated with the freeze-all strategy, the single GnRHa trigger is recommended for final oocyte maturation, which can prevent the occurrence of moderate to severe OHSS and obtain satisfactory pregnancy and neonatal outcomes in subsequent FET cycles.
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Affiliation(s)
- Yuxia He
- Department of Obstetrics and Gynecology, Center of Reproductive Medicine, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Key Laboratory for Reproductive Medicine of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yan Tang
- Department of Obstetrics and Gynecology, Center of Reproductive Medicine, Zhongshan City People's Hospital, Zhongshan, China
| | - Shiping Chen
- Department of Obstetrics and Gynecology, Center of Reproductive Medicine, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Key Laboratory for Reproductive Medicine of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jianqiao Liu
- Department of Obstetrics and Gynecology, Center of Reproductive Medicine, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Key Laboratory for Reproductive Medicine of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Haiying Liu
- Department of Obstetrics and Gynecology, Center of Reproductive Medicine, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China. .,Key Laboratory for Reproductive Medicine of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China. .,Department of Reproductive Medicine, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Guangzhou, Guangdong, China.
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19
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Sloth A, Kjølhede M, Sarmon KG, Knudsen UB. Effect of dual trigger on reproductive outcome in low responders: a systematic PRISMA review and meta-analysis. Gynecol Endocrinol 2022; 38:213-221. [PMID: 34779694 DOI: 10.1080/09513590.2021.2000962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE Poor ovarian responders (PORs) pose a great challenge for fertility clinics worldwide. The aim of this study was to examine whether 'dual trigger' consisting of human chorionic gonadotropin (hCG) plus gonadotropin-releasing hormone agonist (GnRHa) is beneficial or not regarding implantation rate, pregnancy rate, and live birth rate for POR. METHODS This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Risk of bias was evaluated by the Newcastle-Ottawa scale or version 2 (NOS) of the Cochrane risk-of-bias tool for randomized trials (ROB2) independently by two authors. Furthermore, RevMan version 5.4 was used to analyze the extracted data and to create an inverse-weighted summary-odds ratio (OR). RESULTS A total of 1390 studies were screened. Seven studies containing a total of 2474 POR were included. The pooled meta-analysis revealed a 1.62-fold increase in clinical pregnancy rate (OR = 1.62 [1.00, 2.62], p = .05) and a 2.65-fold increase in live birth rate (OR = 2.65 [1.66, 4.24], p < .0001) in the dual trigger group compared to hCG trigger. The pooled analysis showed no significant difference between the two groups regarding implantation rate (OR = 1.14 [0.93, 1.39], p = .21). CONCLUSIONS The meta-analysis of this study indicates that dual trigger as finale oocyte maturation is advantageous compared to hCG trigger among POR. However, large-scale, high-quality, randomized controlled trials (RCT) are required to confirm this conclusion and fully address the magnitude of this effect.
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Affiliation(s)
- Amalie Sloth
- Department of Urology, Aalborg University Hospital, Aalborg, Denmark
| | - Maria Kjølhede
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Ulla Breth Knudsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Obstetrics and Gynecology, Horsens Regional Hospital, Horsens, Denmark
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20
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Ganer Herman H, Horowitz E, Mizrachi Y, Farhi J, Raziel A, Weissman A. Prediction, assessment, and management of suboptimal GnRH agonist trigger: a systematic review. J Assist Reprod Genet 2022; 39:291-303. [PMID: 35306603 PMCID: PMC8956771 DOI: 10.1007/s10815-021-02359-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 11/15/2021] [Indexed: 02/03/2023] Open
Abstract
PURPOSE This systematic review aimed to identify baseline patient demographic and controlled ovarian stimulation characteristics associated with a suboptimal response to GnRHa triggering, and available options for prevention and management of suboptimal response. METHODS PubMed, Google Scholar, Medline, and the Cochrane Library were searched for keywords related to GnRHa triggering, and peer-reviewed articles from January 2000 to September 2021 included. RESULTS Thirty-seven studies were included in the review. A suboptimal response to GnRHa triggering was more likely following long-term or recent oral contraceptive use and with a low or high body mass index. Low basal serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol serum levels were correlated with suboptimal oocyte yield, as was a low serum LH level on the day of triggering. A prolonged stimulation period and increased gonadotropin requirements were correlated with suboptimal response to triggering. Post-trigger LH < 15 IU/L best correlated with an increased risk for empty follicle syndrome and a lower oocyte retrieval rate. Retriggering with hCG may be considered in patients with suboptimal response according to post-trigger LH, as in cases of failed aspiration. CONCLUSION Pre-treatment assessment of patient characteristics, with pre- and post-triggering assessment of clinical and endocrine cycle characteristics, may identify cases at risk for suboptimal response to GnRHa triggering and optimize its utilization.
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Affiliation(s)
- Hadas Ganer Herman
- grid.12136.370000 0004 1937 0546In Vitro Fertilization Unit, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Horowitz
- grid.12136.370000 0004 1937 0546In Vitro Fertilization Unit, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yossi Mizrachi
- grid.12136.370000 0004 1937 0546In Vitro Fertilization Unit, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jacob Farhi
- grid.12136.370000 0004 1937 0546In Vitro Fertilization Unit, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arieh Raziel
- grid.12136.370000 0004 1937 0546In Vitro Fertilization Unit, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ariel Weissman
- grid.12136.370000 0004 1937 0546In Vitro Fertilization Unit, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Association between different dual trigger dosages and IVF results in patients with POSEIDON Group IV. Obstet Gynecol Sci 2022; 65:215-222. [PMID: 35081677 PMCID: PMC8942747 DOI: 10.5468/ogs.21317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/10/2022] [Indexed: 11/29/2022] Open
Abstract
Objective Dual trigger is used to induce final oocyte maturation during the process of controlled ovarian hyperstimulation, yet yielding controversial results. Also, there are yet no data regarding the effect of the dosage of the dual trigger on clinical outcomes. Based on the Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number (POSEIDON) criteria, this study aimed to determine the clinical difference of a single bolus versus two boluses of gonadotropin-releasing hormone agonist (GnRHa) in POSEIDON group IV patients using dual trigger. Methods We screened a total of 1,256 patients who underwent in vitro fertilization (IVF) cycles who met the POSEIDON group IV criteria. Six hundred and twenty-nine patients received one bolus of GnRHa, and 627 patients were given two boluses. All patients received the same dose of recombinant human chorionic gonadotropin during the dual trigger cycle. Results Metaphase II oocyte retrieval rate, fertilization rate and clinical pregnancy rate did not differ between the two groups. However, a lower percentage of at least one top-quality embryo transfer (34.3% vs. 26.0%, P=0.001) in the two bolus-GnRHa group was noted. Conclusion A double bolus of GnRHa did not show superior clinical results compared to a single bolus of GnRHa in the dual trigger IVF cycle. Therefore, GnRHa doses for use should be decided based on individual clinical situations considering cost-effectiveness and patient compliance, but further investigation will be needed.
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Merkison J, Malcom C, Decherney A. Use of gonadotropin-releasing hormone (GnRH) agonist trigger in fertility preservation for patients with inherited genetic disorders. Front Endocrinol (Lausanne) 2022; 13:826419. [PMID: 36147559 PMCID: PMC9486700 DOI: 10.3389/fendo.2022.826419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 07/28/2022] [Indexed: 11/20/2022] Open
Abstract
In patients with varying hematologic disorders (thalassemia, sickle cell anemia, aplastic anemia, etc.), inherited bone marrow failure syndromes, and immune deficiencies due to a single gene disorder, the advent of stem cell transplantation (SCT) as a treatment option has allowed for significant disease improvement, and possibly cure. This specific treatment option often requires exposure to chemotherapeutic agents and sometimes whole body radiation; therefore, primary ovarian insufficiency is often sequelae of the therapy. The optimization of fertility preservation protocols within this patient population is of extreme importance. This review aims to detail the use of GnRH agonist use within this patient population, within the context of fertility preservation cycles.
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Affiliation(s)
- Jamie Merkison
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, The National Institutes of Health, Bethesda, MD, United States
| | - Carrie Malcom
- Department of Obstetrics and Gynecology, Jackson Health System, Miami, FL, United States
| | - Alan Decherney
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, The National Institutes of Health, Bethesda, MD, United States
- *Correspondence: Alan Decherney,
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Sharma R, Meena I. To Compare the Effect of GnRH Agonist versus Human Chorionic Gonadotropin (HCG) Trigger on Clinical Pregnancy Rate in Intrauterine Insemination Cycle. J Hum Reprod Sci 2021; 14:267-272. [PMID: 34759616 PMCID: PMC8527070 DOI: 10.4103/jhrs.jhrs_100_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 03/26/2021] [Accepted: 06/09/2021] [Indexed: 11/05/2022] Open
Abstract
Context: Gonadotropin-releasing hormone (GnRH) agonist trigger mimics the natural surge more closely with both luteinizing hormone (LH) and follicle-stimulating hormone surge. The present study attempts to find whether this apparent physiological advantage translates into the better pregnancy rate. Aims: To compare the effect of GnRH agonist versus human chorionic gonadotropin (hCG) trigger on the clinical pregnancy rate (CPR) in infertile women undergoing intrauterine insemination (IUI) with oral ovulogens. Settings and Design: Retrospective analysis at a tertiary care in vitro fertilization center. Materials and Methods: The records of 280 infertile women, who underwent IUI with oral ovulogens were analyzed. Women who received 0.2 mg triptorelin (GnRH agonist (GnRHa)) as trigger were categorised in Group A (n = 129) and those who received 10,000 IU urinary hCG in Group B (n = 151). The outcome in terms of CPR was studied. Statistical Analysis Used: The quantitative variables were compared using the independent t-test/Mann–Whitney test. The qualitative variables were compared using the Chi-square test. P < 0.05 was considered statistically significant. Results: There was a trend toward better CPR in Group A (21/129 – 16.28%) than in Group B (16/151 – 10.60%), although the difference was not found to be statistically significant (P – 0.162). Conclusions: There was a trend toward better CPR with the use of GnRH agonist trigger in IUI cycles with oral ovulogens in comparison to hCG trigger, although the difference was not found to be statistically significant. Further randomized controlled trials are needed to confirm these findings.
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Affiliation(s)
- Rashmi Sharma
- IVF and Reproductive medicine, Origyn fertility and IVF, 4 floor HB Twin Tower-2 NSP Near D Mall, Pitampura New Delhi -110 034, India
| | - Imlesh Meena
- IVF and Reproductive medicine, Origyn fertility and IVF, 4 floor HB Twin Tower-2 NSP Near D Mall, Pitampura New Delhi -110 034, India
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Alsbjerg B, Kesmodel US, Elbaek HO, Laursen R, Laursen SB, Andreasen D, Povlsen BB, Humaidan P. GnRH agonist supplementation in hormone replacement therapy-frozen embryo transfer cycles: a randomized controlled trial. Reprod Biomed Online 2021; 44:261-270. [PMID: 34924287 DOI: 10.1016/j.rbmo.2021.10.019] [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: 05/18/2021] [Revised: 10/14/2021] [Accepted: 10/20/2021] [Indexed: 11/18/2022]
Abstract
RESEARCH QUESTION Will two boluses of gonadotrophin-releasing hormone agonist (GnRHa) during hormone replacement therapy-frozen embryo transfer (HRT-FET) cycles reduce the total pregnancy loss rate? DESIGN Randomized controlled trial including a total of 287 HRT-FET cycles performed between 2013 and 2019. After randomization participants allocated to the GnRHa group (n = 144) underwent a standard HRT protocol, supplemented with a total of two boluses of triptorelin 0.1 mg; one bolus 2 days before starting vaginal progesterone and one bolus on the 7th day of progesterone. The control group (n = 143) underwent a standard HRT-FET protocol only. RESULTS The intention-to-treat analysis showed no significant difference in total pregnancy loss between the GnRHa group and the control group (21% versus 33%; relative risk [RR] 0.63, 95% confidence interval [CI] 0.35-1.11), nor was the biochemical pregnancy loss per positive human chorionic gonadotrophin (HCG) significantly lower in the GnRHa group (12%, 8/67) compared with the control group (25%, 18/72) (RR 0.48, 95% CI 0.22-1.02). Participants with a live birth had a significantly higher mean progesterone concentration compared with participants without a live birth (25.0 ± 12.2 versus 23.8 ± 8.9 nmol/l; P = 0.001). Furthermore, a trend for a higher live birth rate (LBR) correlated with the highest oestradiol quartile concentration (oestradiol >0.957 nmol/l). CONCLUSIONS Although a difference of 14% in biochemical loss and 12% in total pregnancy loss in favour of GnRHa supplementation was seen this did not reach statistical difference. Luteal progesterone and oestradiol concentrations correlate with LBR in the HRT-FET cycle, emphasizing the importance of luteal serum progesterone and oestradiol monitoring.
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Affiliation(s)
- Birgit Alsbjerg
- The Fertility Clinic, Skive Regional Hospital, Skive, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Ulrik S Kesmodel
- Department of Obstetrics and Gynaecology, Aalborg University Hospital, Aalborg, Denmark
| | - Helle O Elbaek
- The Fertility Clinic, Skive Regional Hospital, Skive, Denmark
| | - Rita Laursen
- The Fertility Clinic, Skive Regional Hospital, Skive, Denmark
| | | | | | | | - Peter Humaidan
- The Fertility Clinic, Skive Regional Hospital, Skive, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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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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Hu KL, Wang S, Ye X, Zhang D, Hunt S. GnRH agonist and hCG (dual trigger) versus hCG trigger for follicular maturation: a systematic review and meta-analysis of randomized trials. Reprod Biol Endocrinol 2021; 19:78. [PMID: 34059045 PMCID: PMC8167939 DOI: 10.1186/s12958-021-00766-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Traditionally, final follicular maturation is triggered by a single bolus of human chorionic gonadotropin (hCG). This acts as a surrogate to the naturally occurring luteinizing hormone (LH) surge to induce luteinization of the granulosa cells, resumption of meiosis and final oocyte maturation. More recently, a bolus of gonadotropin-releasing hormone (GnRH) agonist in combination with hCG (dual trigger) has been suggested as an alternative regimen to achieve final follicular maturation. METHODS This study was a systematic review and meta-analysis of randomized trials evaluating the effect of dual trigger versus hCG trigger for follicular maturation on pregnancy outcomes in women undergoing in vitro fertilization (IVF). The primary outcome was the live birth rate (LBR) per started cycle. RESULTS A total of 1048 participants were included in the analysis, with 519 in the dual trigger group and 529 in the hCG trigger group. Dual trigger treatment was associated with a significantly higher LBR per started cycle compared with the hCG trigger treatment (risk ratio (RR) = 1.37 [1.07, 1.76], I2 = 0%, moderate evidence). There was a trend towards an increase in both ongoing pregnancy rate (RR = 1.34 [0.96, 1.89], I2 = 0%, low evidence) and implantation rate (RR = 1.31 [0.90, 1.91], I2 = 76%, low evidence) with dual trigger treatment compared with hCG trigger treatment. Dual trigger treatment was associated with a significant increase in clinical pregnancy rate (RR = 1.29 [1.10, 1.52], I2 = 13%, low evidence), number of oocytes collected (mean difference (MD) = 1.52 [0.59, 2.46), I2 = 53%, low evidence), number of mature oocytes collected (MD = 1.01 [0.43, 1.58], I2 = 18%, low evidence), number of fertilized oocytes (MD = 0.73 [0.16, 1.30], I2 = 7%, low evidence) and significantly more usable embryos (MD = 0.90 [0.42, 1.38], I2 = 0%, low evidence). CONCLUSION Dual trigger treatment with GnRH agonist and HCG is associated with an increased live birth rate compared with conventional hCG trigger. TRIAL REGISTRATION CRD42020204452 .
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Affiliation(s)
- Kai-Lun Hu
- grid.13402.340000 0004 1759 700XKey Laboratory of Reproductive Genetics (Ministry of Education) and Department of Reproductive Endocrinology, Women’s Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310006 P. R. China
- Key Laboratory of Women’s Reproductive Health of Zhejiang Province, Hangzhou, Zhejiang 310006 P. R. China
| | - Siwen Wang
- grid.13402.340000 0004 1759 700XKey Laboratory of Reproductive Genetics (Ministry of Education) and Department of Reproductive Endocrinology, Women’s Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310006 P. R. China
| | - Xiaohang Ye
- grid.13402.340000 0004 1759 700XKey Laboratory of Reproductive Genetics (Ministry of Education) and Department of Reproductive Endocrinology, Women’s Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310006 P. R. China
| | - Dan Zhang
- grid.13402.340000 0004 1759 700XKey Laboratory of Reproductive Genetics (Ministry of Education) and Department of Reproductive Endocrinology, Women’s Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310006 P. R. China
- Key Laboratory of Women’s Reproductive Health of Zhejiang Province, Hangzhou, Zhejiang 310006 P. R. China
| | - Sarah Hunt
- grid.1002.30000 0004 1936 7857Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria Australia
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Gao F, Wang Y, Fu M, Zhang Q, Ren Y, Shen H, Han H. Effect of a "Dual Trigger" Using a GnRH Agonist and hCG on the Cumulative Live-Birth Rate for Normal Responders in GnRH-Antagonist Cycles. Front Med (Lausanne) 2021; 8:683210. [PMID: 34113641 PMCID: PMC8185054 DOI: 10.3389/fmed.2021.683210] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 05/03/2021] [Indexed: 11/16/2022] Open
Abstract
“Dual triggering” for final oocyte maturation using a combination of a gonadotropin-releasing hormone agonist (GnRHa) and human chorionic gonadotropin (hCG) can improve clinical outcomes in high responders during in vitro fertilization–intracytoplasmic sperm injection (IVF–ICSI) GnRH-antagonist cycles. However, whether this dual trigger is also beneficial to normal responders is not known. We retrospectively analyzed the data generated from 469 normal responders from 1 January to 31 December 2017. The final oocyte maturation was undertaken with a dual trigger with a GnRHa combined with hCG (n = 270) or hCG alone (n = 199). Patients were followed up for 3 years. The cumulative live-birth rate was calculated as the first live birth achieved after all cycles having an embryo transfer (cycles using fresh embryos and frozen–thawed embryos) among both groups. Women in the dual-trigger group achieved a slightly higher number of oocytes retrieved (11.24 vs. 10.24), higher number of two-pronuclear (2PN) embryos (8.37 vs. 7.67) and a higher number of embryos available (4.45 vs. 4.03). However, the cumulative live-birth rate and the all-inclusive success rate for assisted reproductive technology was similar between the two groups (54.07 vs. 59.30%). We showed that a dual trigger was not superior to a hCG-alone trigger for normal responders in GnRH-antagonist cycles in terms of the cumulative live-birth rate.
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Affiliation(s)
- Fumei Gao
- Reproductive Center of Peking University Peoples' Hospital, Beijing, China
| | - Yanbin Wang
- Reproductive Center of Peking University Peoples' Hospital, Beijing, China
| | - Min Fu
- Reproductive Center of Peking University Peoples' Hospital, Beijing, China
| | - Qiuxiang Zhang
- Reproductive Center of Peking University Peoples' Hospital, Beijing, China
| | - Yumeng Ren
- Reproductive Center of Peking University Peoples' Hospital, Beijing, China
| | - Huan Shen
- Reproductive Center of Peking University Peoples' Hospital, Beijing, China
| | - Hongjing Han
- Reproductive Center of Peking University Peoples' Hospital, Beijing, China
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Hershko Klement A, Orvieto R, Esh Broder E, Frei J, Solnica A, Zandman O, Holzer H, Haas J. How far is too far? Does time interval between GnRH antagonist and GnRH agonist trigger in GnRH antagonist cycles matter? Reprod Biomed Online 2021; 43:233-238. [PMID: 34215488 DOI: 10.1016/j.rbmo.2021.05.004] [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: 03/22/2021] [Revised: 04/28/2021] [Accepted: 05/01/2021] [Indexed: 10/21/2022]
Abstract
RESEARCH QUESTION What is a suitable time interval between the last GnRH antagonist exposure and GnRH agonist (GnRHa) triggering for final follicular maturation? DESIGN A retrospective cohort study including 413 patients undergoing GnRH antagonist cycles in which GnRHa trigger was used, either solely or as a dual trigger. The primary outcome measure was the follicle/mature oocyte ratio. Cycles were analysed according to the time interval between the last GnRH antagonist exposure and the GnRHa triggering: Group 1 included patients with a 12-14 h interval; Group 2: 7-10 h interval; Group 3: 5-6 h interval and Group 4: 2-4 h interval. LH concentration was measured 11-13 h post-GnRHa injection. RESULTS Median LH value was 65 IU/l. There was a weak but significant correlation between basal LH and the LH surge (R2 = 0.137, P < 0.001). Although square root LH values differed significantly between study groups (P < 0.001; higher in Groups 2 and 3), the follicle/mature oocyte ratio was not different across the four antagonist-agonist interval groups and no correlation was detected between the post-trigger LH concentration and the follicle/oocyte ratio (R2 = 0.011). In a model integrating age, day 3 FSH concentration, maximal oestradiol and body mass index along with the study groups, none of these factors was significantly related to the follicle/mature oocyte outcome ratio. Insufficient surge (LH < 15 IU/l) occurred in 14 (3.4%) cases. Rates of insufficient LH surge did not differ significantly between the groups (2.4%, 3.2%, 3.4% and 7.1% in Groups 1 to 4, respectively; P = 0.5). CONCLUSIONS LH concentrations post-GnRHa trigger differ in regard to antagonist-agonist intervals, but the follicle/mature oocyte ratio achieved was not affected.
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Affiliation(s)
- Anat Hershko Klement
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Mt. Scopus Jerusalem, Israel; Faculty of Medicine, The Hebrew University Jerusalem, Israel.
| | - Raoul Orvieto
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hasomer, Israel; The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Efrat Esh Broder
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Mt. Scopus Jerusalem, Israel; Faculty of Medicine, The Hebrew University Jerusalem, Israel
| | - Judith Frei
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hasomer, Israel
| | - Amy Solnica
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Mt. Scopus Jerusalem, Israel; Henrietta Szold School of Nursing, Faculty of Medicine, The Hebrew University Jerusalem, Israel
| | - Orit Zandman
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hasomer, Israel
| | - Hananel Holzer
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Mt. Scopus Jerusalem, Israel; Faculty of Medicine, The Hebrew University Jerusalem, Israel
| | - Jigal Haas
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hasomer, Israel; The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Oliveira CMD, Oliveira CAMD, Fonseca LL, Souza KRRD, Radaelli MRM. GnRH agonist in association with hCG versus hCG alone for final oocyte maturation triggering in GnRH antagonist cycles. JBRA Assist Reprod 2021; 25:246-251. [PMID: 33507721 PMCID: PMC8083849 DOI: 10.5935/1518-0557.20200089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Objective: To analyze gonadotropin-releasing hormone (GnRH) agonist in association with human chorionic gonadotropin (hCG) (dual triggering) versus hCG alone (conventional triggering) for final oocyte maturation triggering in GnRH antagonist cycles in an unselected population of Brazilian women. Methods: This prospective case-control study involved 114 patients referred to autologous in vitro fertilization treatment between February 2018 and August 2019, recruited regardless of age, infertility factor or number of cycles. The patients were randomly allocated into two groups according to oocyte maturation triggering approach: group A (n = 48) - hCG only; and group B (n = 66) - hCG plus GnRH agonist. The main outcomes measured were the number of total and metaphase II (MII) oocytes retrieved. Results: The groups were homogenous in terms of age. There were no moderate or severe ovarian hyperstimulation syndrome events. There were no statistical differences concerning total or MII oocytes retrieved between the groups (p > 0.05). The MII/total oocyte rate was 70.9% in group A, and 74.5% in group B (p = 0.679). There was no oocyte retrieved in 2/48 patients (4.16%) in group A, 1/66 (1.5%) in group B. There were no MII oocytes in 4/48 patients (8.3%) in group A, and 2/66 (3%) in group B. Age was directly correlated to the number of total and MII oocytes retrieved (p < 0.05). Conclusions: Dual triggering was equivalent to conventional hCH triggering in terms of the number of total and MII oocytes retrieved in the general population. Further studies are necessary to ascertain dual triggering indication in selected groups of women.
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Haas J, Bassil R, Samara N, Zilberberg E, Mehta C, Orvieto R, Casper RF. GnRH agonist and hCG (dual trigger) versus hCG trigger for final follicular maturation: a double-blinded, randomized controlled study. Hum Reprod 2021; 35:1648-1654. [PMID: 32563188 DOI: 10.1093/humrep/deaa107] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 04/18/2020] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTION Does co-administration of GnRH agonist and Human chorionic gonadotropin (hCG; dual trigger) in IVF cycles improve the number of mature oocytes and pregnancy outcome compared to hCG alone? SUMMARY ANSWER Using the dual trigger for final follicular maturation increases the number of oocytes, mature oocytes and number of blastocysts (total and top-quality) compared to triggering with hCG alone. WHAT IS KNOWN ALREADY hCG is used at the end of controlled ovarian hyperstimulation as a surrogate LH surge to induce final oocyte maturation. Recently, based on retrospective studies, the co-administration of GnRH agonist and hCG for final oocyte maturation (dual trigger) has been suggested to improve IVF outcome and pregnancy rates. STUDY DESIGN, SIZE, DURATION A single center, randomized controlled, double-blinded clinical trial between May 2016 and June 2018 analyzed by intention to treat (ITT). PARTICIPANTS/MATERIALS, SETTINGS, METHODS One hundred and fifty-five normal responder patients were randomized either to receive hCG or dual trigger for final oocyte maturation. Data on patients age, BMI, AMH, number of oocytes retrieved, number of metaphase 2 (MII) oocytes, zygotes and blastocysts, clinical pregnancy rate and live birth rate were assessed and compared between the dual trigger group and the hCG group. We performed a planned interim analysis after the recruitment of 50% of the patients. Based on the totality of outcomes at the interim analysis we decided to discontinue further recruitment. MAIN RESULTS AND THE ROLE OF CHANCE One hundred and fifty-five patients were included in the study. The age (36 years versus 35.3 years P = NS), BMI (24 kg/m2 versus 23.7 kg/m2) and the AMH (20.1 pmol/l versus 22.4 pmol/l) were comparable between the two groups. Based on ITT analysis, the number of eggs retrieved (11.1 versus 13.4, P = 0.002), the MII oocytes (8.6 versus 10.3, P = 0.009), total number of blastocysts (2.9 versus 3.9, P = 0.01) and top-quality blastocysts transferred (44.7% versus 64.9%; P = 0.003) were significantly higher in the dual trigger group compared to the hCG group. The clinical pregnancy rate (24.3% versus 46.1%, OR 2.65 (1.43-1.93), P = 0.009) and the live birth rate per transfer (22% versus 36.2%, OR= 1.98 (1.05-3.75), P = 0.03) were significantly higher in the dual trigger group compared to the hCG group. LIMITATIONS, REASONS FOR CAUTION None. WIDER IMPLICATIONS OF THE FINDINGS The enhanced response observed with the dual trigger might lead to better IVF outcomes were it used more widely. STUDY FUNDING/COMPETING INTEREST(S) The study was funded by TRIO Fertility. There are no conflicts of interest to declare. TRIAL REGISTRATION NUMBER ClinicalTrials.gov identifier: NCT02703584. DATE OF TRIAL REGISTRATION March 2016. DATE OF FIRST PATIENT'S ENROLLMENT May 2016.
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Affiliation(s)
- J Haas
- TRIO Fertility, Toronto, ON, Canada.,IVF Unit, Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - R Bassil
- TRIO Fertility, Toronto, ON, Canada
| | - N Samara
- TRIO Fertility, Toronto, ON, Canada
| | - E Zilberberg
- TRIO Fertility, Toronto, ON, Canada.,IVF Unit, Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - C Mehta
- TRIO Fertility, Toronto, ON, Canada
| | - R Orvieto
- IVF Unit, Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - R F Casper
- TRIO Fertility, Toronto, ON, Canada.,Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada.,Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
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Luteal Support with very Low Daily Dose of Human Chorionic Gonadotropin after Fresh Embryo Transfer as an Alternative to Cycle Segmentation for High Responders Patients Undergoing Gonadotropin-Releasing Hormone Agonist-Triggered IVF. Pharmaceuticals (Basel) 2021; 14:ph14030228. [PMID: 33800021 PMCID: PMC7998839 DOI: 10.3390/ph14030228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 11/16/2022] Open
Abstract
The segmentation of the in vitro fertilization (IVF) cycle, consisting of the freezing of all embryos and the postponement of embryo transfer (ET), has become popular in recent years, with the main purpose of preventing ovarian hyperstimulation syndrome (OHSS) in patients with high response to controlled ovarian stimulation (COS). Indeed cycle segmentation (CS), especially when coupled to a GnRH-agonist trigger, was shown to reduce the incidence of OHSS in high-risk patients. However, CS increases the economic costs and the work amount for IVF laboratories. An alternative strategy is to perform a fresh ET in association with intensive luteal phase pharmacological support, able to overcome the negative effects of the GnRH-agonist trigger on the luteal phase and on endometrial receptivity. In order to compare these two strategies, we performed a retrospective, real-life cohort study including 240 non-polycystic ovarian syndrome (PCO) women with expected high responsiveness to COS (AMH >2.5 ng/mL), who received either fresh ET plus 100 IU daily human chorionic gonadotropin (hCG) as luteal support (FRESH group, n = 133), or cycle segmentation with freezing of all embryos and postponed ET (CS group, n = 107). The primary outcomes were: implantation rate (IR), live birth rate (LBR) after the first ET, and incidence of OHSS. Overall, significantly higher IR and LBR were observed in the CS group than in the FRESH group (42.9% vs. 27.8%, p < 0.05 and 32.7% vs. 19.5%, p < 0.05, respectively); the superiority of CS strategy was particularly evident when 16-19 oocytes were retrieved (LBR 42.2% vs. 9.5%, p = 0.01). Mild OHSS appeared with the same incidence in the two groups, whereas moderate and severe OHSS forms were observed only in the FRESH group (1.5% and 0.8%, respectively). In conclusion, in non-PCO women, high responders submitted to COS with the GnRH-antagonist protocol and GnRH-agonist trigger, CS strategy was associated with higher IR and LBR than the strategy including fresh ET followed by luteal phase support with a low daily hCG dose. CS appears to be advisable, especially when >15 oocytes are retrieved.
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Oocyte competence is independent of the ovulation trigger adopted: a large observational study in a setting that entails vitrified-warmed single euploid blastocyst transfer. J Assist Reprod Genet 2021; 38:1419-1427. [PMID: 33661465 DOI: 10.1007/s10815-021-02124-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/21/2021] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To assess whether the GnRH-agonist or urinary-hCG ovulation triggers affect oocyte competence in a setting entailing vitrified-warmed euploid blastocyst transfer. METHODS Observational study (April 2013-July 2018) including 2104 patients (1015 and 1089 in the GnRH-a and u-hCG group, respectively) collecting ≥1 cumulus-oocyte-complex (COC) and undergoing ICSI with ejaculated sperm, blastocyst culture, trophectoderm biopsy, comprehensive-chromosome-testing, and vitrified-warmed transfers at a private clinic. The primary outcome measure was the euploid-blastocyst-rate per inseminated oocytes. The secondary outcome measure was the maturation-rate per COCs. Also, the live-birth-rate (LBR) per transfer and the cumulative-live-birth-delivery-rate (CLBdR) among completed cycles were investigated. All data were adjusted for confounders. RESULTS The generalized-linear-model adjusted for maternal age highlighted no difference in the mean euploid-blastocyst-rate per inseminated oocytes in either group. The LBR per transfer was similar: 44% (n=403/915) and 46% (n=280/608) in GnRH-a and hCG, respectively. On the other hand, a difference was reported regarding the CLBdR per oocyte retrieval among completed cycles, with 42% (n=374/898) and 25% (n=258/1034) in the GnRh-a and u-hCG groups, respectively. Nevertheless, this variance was due to a lower maternal age and higher number of inseminated oocytes in the GnRH-a group, and not imputable to the ovulation trigger itself (multivariate-OR=1.3, 95%CI: 0.9-1.6, adjusted p-value=0.1). CONCLUSION GnRH-a trigger is a valid alternative to u-hCG in freeze-all cycles, not only for patients at high risk for OHSS. Such strategy might increase the safety and flexibility of controlled-ovarian-stimulation with no impact on oocyte competence and IVF efficacy.
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Abstract
In vitro fertilization is indicated for infertile women with polycystic ovarian syndrome (PCOS) after unsuccessful treatment with ovulation induction agents or in women deemed high-risk of multiple gestations who are ideal candidates for single embryo transfers. PCOS patients are at increased risk of ovarian hyperstimulation syndrome; therefore, attention should be made in the choice of in vitro fertilization treatment protocol, dose of gonadotropin utilized, and regimen to achieve final oocyte maturation. Adopting these strategies in addition to close monitoring may significantly reduce the ovarian hyperstimulation syndrome risk. Future developments may improve pregnancy outcomes and decrease complications in PCOS women undergoing fertility treatment.
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Tesarik J, Conde-López C, Galán-Lázaro M, Mendoza-Tesarik R. Luteal Phase in Assisted Reproductive Technology. FRONTIERS IN REPRODUCTIVE HEALTH 2020; 2:595183. [PMID: 36304702 PMCID: PMC9580649 DOI: 10.3389/frph.2020.595183] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 11/02/2020] [Indexed: 09/16/2023] Open
Abstract
Luteal phase (LP) is the period of time beginning shortly after ovulation and ending either with luteolysis, shortly before menstrual bleeding, or with the establishment of pregnancy. During the LP, the corpus luteum (CL) secretes progesterone and some other hormones that are essential to prepare the uterus for implantation and further development of the embryo, the function known as uterine receptivity. LP deficiency (LPD) can occur when the secretory activity of the CL is deficient, but also in cases of normal CL function, where it is caused by a defective endometrial response to normal levels of progesterone. LPD is particularly frequent in treatments using assisted reproductive technology (ART). Controlled ovarian stimulation usually aims to obtain the highest number possible of good-quality oocytes and requires the use of gonadotropin-releasing hormone (GnRH) analogs, to prevent premature ovulation, as well as an ovulation trigger to achieve timed final oocyte maturation. Altogether, these treatments suppress pituitary secretion of luteinizing hormone (LH), required for the formation and early activity of the CL. In addition to problems of endometrial receptivity for embryos, LPD also leads to dysfunction of the local uterine immune system, with an increased risk of embryo rejection, abnormally high uterine contractility, and restriction of uterine blood flow. There are two alternatives of LPD prevention: a direct administration of exogenous progesterone to restore the physiological progesterone serum concentration independently of the CL function, on the one hand, and treatments aimed to stimulate the CL activity so as to increase endogenous progesterone production, on the other hand. In case of pregnancy, some kind of LP support is often needed until the luteal-placental shift occurs. If LPD is caused by defective response of the endometrium and uterine immune cells to normal concentrations of progesterone, a still poorly defined condition, symptomatic treatments are the only available solution currently available.
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Şükür YE, Ulubaşoğlu H, İlhan FC, Berker B, Sönmezer M, Atabekoğlu CS, Aytaç R, Özmen B. Dual trigger in normally-responding assisted reproductive technology patients increases the number of top-quality embryos. Clin Exp Reprod Med 2020; 47:300-305. [PMID: 33113599 PMCID: PMC7711097 DOI: 10.5653/cerm.2020.03804] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/14/2020] [Indexed: 11/21/2022] Open
Abstract
Objective The feasibility of a gonadotropin-releasing hormone agonist (GnRHa) trigger in normal responders is still a matter of debate. The aim of this study was to compare the number of mature oocytes, the number of good-quality embryos, and the live birth rate in normal responders triggered by GnRHa alone, GnRHa and human chorionic gonadotropin (hCG; a dual trigger), and hCG alone. Methods A retrospective cohort study was conducted at the infertility clinic of a university hospital. Data from 200 normal responders who underwent controlled ovarian hyperstimulation and intracytoplasmic sperm injection with a GnRH antagonist protocol between January 2016 and January 2017 were reviewed. The first study group consisted of patients with cycles triggered by GnRHa alone. The second study group consisted of patients with cycles triggered by both GnRHa and low-dose hCG (a dual trigger). The control group consisted of patients with cycles triggered by hCG alone. Results The groups were comparable in terms of demographics and cycle characteristics. The numbers of total oocytes retrieved and metaphase II oocytes were similar between the groups. The total numbers of top-quality embryos were 3.2±2.9 in the GnRHa group, 4.4±3.2 in the dual-trigger group, and 2.9±2.1 in the hCG group (p=0.014). The live birth rates were 21.4%, 30.5%, and 28.2% in those groups, respectively (p=0.126). Conclusion In normal responders, a dual-trigger approach appears superior to an hCG trigger alone with regard to the number of top-quality embryos produced. However, no clinical benefit was apparent in terms of live birth rates.
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Affiliation(s)
- Yavuz Emre Şükür
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey
| | - Hasan Ulubaşoğlu
- Department of Obstetrics and Gynecology, Ankara City Hospital, Ankara, Turkey
| | - Fatma Ceylan İlhan
- Department of Obstetrics and Gynecology, Yenimahalle State Hospital, Ankara, Turkey
| | - Bülent Berker
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey
| | - Murat Sönmezer
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey
| | - Cem Somer Atabekoğlu
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey
| | - Ruşen Aytaç
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey
| | - Batuhan Özmen
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey
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36
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Oron G, Sapir O, Wertheimer A, Shufaro Y, Bar-Gil R, Margalit T, Shlush E, Ben-Haroush A. A matched propensity score study of embryo morphokinetics following gonadotropin-releasing hormone agonist versus human chorionic gonadotropin trigger. J Assist Reprod Genet 2020; 37:2777-2782. [PMID: 32980940 DOI: 10.1007/s10815-020-01953-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 09/17/2020] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To compare morphokinetic parameters and quality of embryos derived from GnRH antagonist ICSI cycles triggered either with GnRH agonist or standard hCG between matched groups of patients. METHODS Morphokinetic parameters of embryos derived from matched first GnRH antagonist ICSI cycles triggered by GnRH agonist or standard hCG between 2013 and 2016 were compared. Matching was performed for maternal age, peak estradiol levels, and number of oocytes retrieved. Outcome measures were: time to pronucleus fading (tPNf), cleavage timings (t2-t8), synchrony of the second and third cycles (S2 and S3), duration of the second and third cycle (CC2 and CC3), optimal cell cycle division parameters, and known implantation data (KID) scoring for embryo quality. Multivariate linear and logistic regression analyses were performed for confounding factors. RESULTS We analyzed 824 embryos from 84 GnRH agonist trigger cycles and 746 embryos from 84 matched hCG trigger cycles. Embryos derived from the cycles triggered with hCG triggering cleaved faster than those deriving from GnRH agonist trigger. The differences were significant throughout most stages of embryo development (t3-t6), and a shorter second cell cycle duration of the hCG trigger embryos was observed. There was no difference in synchrony of the second and third cell cycles and the optimal cell cycle division parameters between the two groups, but there was a higher percentage of embryos without multinucleation in the hCG trigger group (27.8% vs. 21.6%, p < 0.001). CONCLUSION The type of trigger in matched antagonist ICSI cycles was found to affect early embryo cleavage times but not embryo quality.
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Affiliation(s)
- Galia Oron
- Infertility and IVF Unit, Helen Schneider Hospital for Women, Rabin Medical Center, Beilinson Hospital, 4941492, Petah Tikva, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Onit Sapir
- Infertility and IVF Unit, Helen Schneider Hospital for Women, Rabin Medical Center, Beilinson Hospital, 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avital Wertheimer
- Infertility and IVF Unit, Helen Schneider Hospital for Women, Rabin Medical Center, Beilinson Hospital, 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoel Shufaro
- Infertility and IVF Unit, Helen Schneider Hospital for Women, Rabin Medical Center, Beilinson Hospital, 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Roni Bar-Gil
- Infertility and IVF Unit, Helen Schneider Hospital for Women, Rabin Medical Center, Beilinson Hospital, 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tamar Margalit
- Infertility and IVF Unit, Helen Schneider Hospital for Women, Rabin Medical Center, Beilinson Hospital, 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ekaterina Shlush
- Infertility and IVF Unit, Helen Schneider Hospital for Women, Rabin Medical Center, Beilinson Hospital, 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avi Ben-Haroush
- Infertility and IVF Unit, Helen Schneider Hospital for Women, Rabin Medical Center, Beilinson Hospital, 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Popovic-Todorovic B, Santos-Ribeiro S, Drakopoulos P, De Vos M, Racca A, Mackens S, Thorrez Y, Verheyen G, Tournaye H, Quintero L, Blockeel C. Predicting suboptimal oocyte yield following GnRH agonist trigger by measuring serum LH at the start of ovarian stimulation. Hum Reprod 2020; 34:2027-2035. [PMID: 31560740 DOI: 10.1093/humrep/dez132] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 06/10/2019] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTION Are the LH levels at the start of ovarian stimulation predictive of suboptimal oocyte yield from GnRH agonist triggering in GnRH antagonist down-regulated cycles? SUMMARY ANSWER LH levels at the start of ovarian stimulation are an independent predictor of suboptimal oocyte yield following a GnRH agonist trigger. WHAT IS KNOWN ALREADY A GnRH agonist ovulation trigger may result in an inadequate oocyte yield in a small subset of patients. This failure can range from empty follicle syndrome to the retrieval of much fewer oocytes than expected. Suboptimal response to a GnRH agonist trigger has been defined as the presence of circulating LH levels <15 IU/l 12 h after triggering. It has been shown that patients with immeasurable LH levels on trigger day have an up to 25% risk of suboptimal response. STUDY DESIGN, SIZE, DURATION In this retrospective cohort study, all patients (n = 3334) who received GnRH agonist triggering (using Triptoreline 0.2 mg) for final oocyte maturation undergoing a GnRH antagonist cycle in our centre from 2011 to 2017 were included. The primary outcome of the study was oocyte yield, defined as the ratio between the total number of collected oocytes and the number of follicles with a mean diameter >10 mm prior to GnRH agonist trigger. PARTICIPANTS/MATERIALS, SETTING, METHODS The endocrine profile of all patients was studied at initiation as well as at the end of ovarian stimulation. In order to evaluate whether LH levels, not only at the end but also at the start, of ovarian stimulation predicted oocyte yield, we performed multivariable regression analysis adjusting for the following confounding factors: female age, body mass index, oral contraceptives before treatment, basal and trigger day estradiol levels, starting FSH levels, use of highly purified human menopausal gonadotrophin and total gonadotropin dose. Suboptimal response to GnRH agonist trigger was defined as <10th percentile of oocyte yield. MAIN RESULTS AND THE ROLE OF CHANCE The average age was 31.9 years, and the mean oocyte yield was 89%. The suboptimal response to GnRH agonist trigger cut-off (<10th percentile) was 45%, which was exhibited by 340 patients. Following confounder adjustment, multivariable regression analysis showed that LH levels at the initiation of ovarian stimulation remained an independent predictor of suboptimal response even in the multivariable model (adjusted OR 0.920, 95% CI 0.871-0.971). Patients with immeasurable LH levels at the start of stimulation (<0.1 IU/l) had a 45.2% risk of suboptimal response, while the risk decreased with increasing basal LH levels; baseline circulating LH <0.5 IU/L, <2 IU/L and <5 IU/L were associated with a 39.1%, 25.2% and 13.6% risk, respectively. LIMITATIONS, REASONS FOR CAUTION The main limitation of the study is its retrospective design. WIDER IMPLICATIONS OF THE FINDINGS This is the largest study of GnRH agonist trigger cycles only, since most of the previous research on the predictive value of basal LH levels was performed in dual trigger cycles. LH values should be measured prior to start of ovarian stimulation. In cases where they are immeasurable, suboptimal response to GnRH agonist trigger can be anticipated, and an individualized approach is warranted. STUDY FUNDING/COMPETING INTEREST(S) There was no funding and no competing interests. TRIAL REGISTRATION NUMBER Not applicable.
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Affiliation(s)
| | - S Santos-Ribeiro
- Centre for Reproductive Medicine, UZ Brussel, Laarbeeklaan, Jette, Belgium.,IVI-RMA, Lisboa, Avenida Infante Dom Henrique, Lisboa, Portugal
| | - P Drakopoulos
- Centre for Reproductive Medicine, UZ Brussel, Laarbeeklaan, Jette, Belgium
| | - M De Vos
- Centre for Reproductive Medicine, UZ Brussel, Laarbeeklaan, Jette, Belgium
| | - A Racca
- Centre for Reproductive Medicine, UZ Brussel, Laarbeeklaan, Jette, Belgium
| | - S Mackens
- Centre for Reproductive Medicine, UZ Brussel, Laarbeeklaan, Jette, Belgium
| | - Y Thorrez
- Centre for Reproductive Medicine, UZ Brussel, Laarbeeklaan, Jette, Belgium
| | - G Verheyen
- Centre for Reproductive Medicine, UZ Brussel, Laarbeeklaan, Jette, Belgium
| | - H Tournaye
- Centre for Reproductive Medicine, UZ Brussel, Laarbeeklaan, Jette, Belgium
| | - L Quintero
- IMER - Instituto de Medicina Reproductiva, Avda. de Burjassot, Valencia, Spain
| | - C Blockeel
- Centre for Reproductive Medicine, UZ Brussel, Laarbeeklaan, Jette, Belgium
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Smitz J, Platteau P. Influence of human chorionic gonadotrophin during ovarian stimulation: an overview. Reprod Biol Endocrinol 2020; 18:80. [PMID: 32762698 PMCID: PMC7409634 DOI: 10.1186/s12958-020-00639-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/29/2020] [Indexed: 12/12/2022] Open
Abstract
It is widely known that luteinising hormone (LH) and human chorionic gonadotrophin (hCG) are integral in the female reproductive lifecycle. Due to the common binding site and similarity in molecular structure, they were previously thought to have overlapping roles. However, with the development of both purified urinary-derived and recombinant gonadotrophins, the individual characteristics of these molecules have begun to be defined. There is evidence to suggest that LH and hCG preferentially activate different signalling cascades and display different receptor-binding kinetics. The data generated on the two molecules have led to an improved understanding of their distinct physiological functions, resulting in a debate among clinicians regarding the most beneficial use of LH- and hCG-containing products for ovarian stimulation (OS) in assisted reproductive technologies (ARTs). Over the past few decades, a number of trials have generated data supporting the use of hCG for OS in ART. Indeed, the data indicated that hCG plays an important role in folliculogenesis, leads to improved endometrial receptivity and is associated with a higher quality of embryos, while presenting a favourable safety profile. These observations support the increased use of hCG as a method to provide LH bioactivity during OS. This review summarises the molecular and functional differences between hCG and LH, and provides an overview of the clinical trial data surrounding the use of products for OS that contain LH bioactivity, examining their individual effect on outcomes such as endometrial receptivity, oocyte yield and embryo quality, as well as key pregnancy outcomes.
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Affiliation(s)
- Johan Smitz
- Follicle Biology Laboratory, Vrije Universiteit Brussel, Laarbeeklaan, 103, 1090 Brussels, Belgium
| | - Peter Platteau
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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Chern CU, Li JY, Tsui KH, Wang PH, Wen ZH, Lin LT. Dual-trigger improves the outcomes of in vitro fertilization cycles in older patients with diminished ovarian reserve: A retrospective cohort study. PLoS One 2020; 15:e0235707. [PMID: 32628729 PMCID: PMC7337315 DOI: 10.1371/journal.pone.0235707] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 06/19/2020] [Indexed: 11/24/2022] Open
Abstract
Background Dual-trigger for final oocyte maturation has been applied on the women with poor ovarian response or diminished ovarian reserve. However, the results were controversial. The Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number (POSEIDON) stratification is a set of newly established criteria for low prognosis patients. The aim of this study was to examine the effectiveness of dual-trigger for final oocyte maturation on the in vitro fertilization (IVF) outcomes of patients who fulfill the POSEIDON group 4 criteria. Methods This retrospective cohort study investigated 384 cycles fulfilling the POSEIDON group 4 criteria. The patients underwent IVF treatment using the gonadotropin-releasing hormone (GnRH) antagonist protocol. The study group contained 194 cycles that received dual-trigger (human chorionic gonadotropin [hCG] plus GnRH-agonist) for final oocyte maturation. The control group included 114 cycles where final oocyte maturation was performed with only hCG. Baseline characteristics and cycle parameters, as well as IVF outcomes of both groups were compared. Results Baseline characteristics were similar between the dual trigger group and the control group. In terms of IVF outcomes, the dual trigger group demonstrated significantly higher number of retrieved oocytes, metaphase II oocytes, fertilized oocytes, day-3 embryos, and top-quality day-3 embryos. A statistically significant improvement in clinical pregnancy rate and live birth rate was also observed in the dual trigger group. Conclusions Our data suggests that dual trigger for final oocyte maturation might improve clinical pregnancy rates and live birth rates of IVF cycles in patients fulfilling the POSEIDON group 4 criteria.
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Affiliation(s)
- Chyi-Uei Chern
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
| | - Ju-Yueh Li
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
| | - Kuan-Hao Tsui
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
- Institute of BioPharmaceutical sciences, National Sun Yat-sen University, Kaohsiung City, Taiwan
- Department of Obstetrics and Gynecology, National Yang-Ming University School of Medicine, Taipei, Taiwan
- Department of Pharmacy and Master Program, College of Pharmacy and Health Care, Tajen University, Pingtung County, Taiwan
| | - Peng-Hui Wang
- Department of Obstetrics and Gynecology, National Yang-Ming University School of Medicine, Taipei, Taiwan
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medical Research, China Medical University Hospital, Taichung City, Taiwan
| | - Zhi-Hong Wen
- Department of Marine Biotechnology and Resources, National Sun Yat-sen University, Kaohsiung City, Taiwan
| | - Li-Te Lin
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
- Institute of BioPharmaceutical sciences, National Sun Yat-sen University, Kaohsiung City, Taiwan
- Department of Obstetrics and Gynecology, National Yang-Ming University School of Medicine, Taipei, Taiwan
- * E-mail:
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Aflatoonian A, Haghighi F, Hoseini M, Haghdani S. Does the repeat dose of gonadotropin-releasing hormone agonist trigger in polycystic ovarian syndrome improve in vitro fertilization cycles outcome? A clinical trial study. Int J Reprod Biomed 2020; 18:485-490. [PMID: 32803113 PMCID: PMC7385917 DOI: 10.18502/ijrm.v13i7.7363] [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: 09/21/2019] [Revised: 12/30/2019] [Accepted: 01/28/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND A repeat dose of Gonadotropin-releasing Hormone (GnRH) agonist could provide long duration of luteinizing hormone (LH) surge and amplitude appropriately. OBJECTIVE Improvement in oocyte maturity could be obtained by a repeat dose of GnRH agonist. MATERIALS AND METHODS In this randomized double-blinded study, 120 women with polycystic ovarian syndrome and serum estradiol level (E2) > 3000 who were candidate for in vitro fertilization with Antagonist protocol were enrolled between July 2018 and July 2019. Participants were randomized in two groups - and final oocyte maturation was triggered with two doses: In group A, a repeat dose of 0.1 mg, 12 hr. after the first dose and in group B, 0.2 mg SC triptorelin (decapeptyl) 35 hr. prior to oocyte retrieval. Serum Estradiol, LH, and progesterone concentration were measured on the trigger day. Serum LH measurement was done three times in both groups. The outcomes were oocyte yield, meiosis (M) I, MII, Maturity rate, germinal vesicle (GV) rate, 2 pronuclear, embryo yield, ovarian hyper stimulation syndrome rates. RESULTS Maturity rate (p = 0.89), MI (p = 0.38), MII (p = 0.89), and GV oocytes (p = 0.38) were not statistically different between the two study groups. LH levels measured at 12 hr post-trigger did not relate statistically significant with maturity rate in our participants (p = 0.96). No empty follicular syndrome was reported. CONCLUSION Although, the second dose of GnRH agonist after 12 hr since the first dose could provide duration of LH surge and amplitude and as a result no empty follicular syndrome was seen, the maturity rate, MI, MII, and GV oocytes were not different between the two study groups.
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Affiliation(s)
- Abbas Aflatoonian
- Department of Obstetrics and Gynecology, Research and Clinical Center for Infertility, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Science, Yazd, Iran.
| | - Fatemeh Haghighi
- Department of Obstetrics and Gynecology, Research and Clinical Center for Infertility, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Science, Yazd, Iran.
| | - Masrooreh Hoseini
- Department of Obstetrics and Gynecology, Research and Clinical Center for Infertility, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Science, Yazd, Iran.
| | - Saeid Haghdani
- Department of Urology, Hasheminejad Kidney Research Center (HKRC), Iran University of Medical Science, Tehran, Iran.
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41
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Rotshenker-Olshinka K, Badeghiesh A, Volodarsky-Perel A, Steiner N, Suarthana E, Dahan MH. Trends in ovarian hyperstimulation syndrome hospitalization rates in the USA: an ongoing concern. Reprod Biomed Online 2020; 41:357-360. [PMID: 32693992 DOI: 10.1016/j.rbmo.2020.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 05/23/2020] [Accepted: 06/09/2020] [Indexed: 11/18/2022]
Abstract
Ovarian hyperstimulation syndrome (OHSS) is a serious, almost exclusively, iatrogenic complication of ovarian stimulation. Many techniques have been developed over the past 25 years to decrease OHSS risks, and most have been in common use for 15-20 years. In view of these techniques, it could be hypothesized that severe OHSS rates would decrease or almost disappear. According to the US National ART Surveillance System, rates did not change significantly between 2000 and 2009, at 106 OHSS cases per 10,000 IVF cycles annually. In the present study, OHSS-related hospital admissions were evaluated to establish whether a decline has occurred in OHSS admissions since the development of preventative strategies. A retrospective-population-based study was conducted using data from the Health-Care Cost and Utilization Project-Nationwide-Inpatient-Sample database between 2004 and 2014 inclusively. Between 2004 and 2008, admissions of OHSS decreased in absolute numbers and rates; however, these statistics plateaued, remaining stable between 2008 and 2014. Despite this, OHSS remains a concern and is clearly not a disease of the past. The financial burden of OHSS hospitalizations likely persists. Although techniques have resulted in a decrease in OHSS admissions since 2004, this change has plateaued, and therefore efforts to further reduce OHSS must continue.
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Affiliation(s)
- Keren Rotshenker-Olshinka
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, McGill University, Montréal Quebec H3A 0G4, Canada; MUHC Reproductive Centre, McGill University, Montréal Quebec H2L 4S8, Canada.
| | - Ahmad Badeghiesh
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, McGill University, Montréal Quebec H3A 0G4, Canada
| | - Alexander Volodarsky-Perel
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, McGill University, Montréal Quebec H3A 0G4, Canada; MUHC Reproductive Centre, McGill University, Montréal Quebec H2L 4S8, Canada
| | - Naama Steiner
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, McGill University, Montréal Quebec H3A 0G4, Canada; MUHC Reproductive Centre, McGill University, Montréal Quebec H2L 4S8, Canada
| | - Eva Suarthana
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, McGill University, Montréal Quebec H3A 0G4, Canada
| | - Michael H Dahan
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, McGill University, Montréal Quebec H3A 0G4, Canada; MUHC Reproductive Centre, McGill University, Montréal Quebec H2L 4S8, Canada
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42
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Oliveira SN, Segabinazzi LGTM, Canuto L, Lisboa FP, Medrado FE, Dell'Aqua JA, Aguiar AJA, Papa FO. Comparative Efficacy of Histrelin Acetate and hCG for Inducing Ovulation in Brazilian Northeastern Jennies (Equus africanus asinus). J Equine Vet Sci 2020; 92:103146. [PMID: 32797776 DOI: 10.1016/j.jevs.2020.103146] [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: 03/30/2020] [Revised: 05/12/2020] [Accepted: 05/25/2020] [Indexed: 10/24/2022]
Abstract
The goal of this study was to compare the efficiency of histrelin acetate (GnRH analog) and human chorionic gonadotropin (hCG) to hasten ovulation in Brazilian Northeastern jennies (Equus africanus asinus). Thirty cycles of ten jennies were randomly assigned in one of the three groups: G0 (control group), saline; G1, 250 μg of histrelin acetate; G2, 2500 IU of hCG. Jennies were evaluated by transrectal palpation and ultrasonography, and had the administration of an ovulation-inducing agent when a follicle measuring between 29 and 32 mm of diameter was diagnosed. Jennies were monitored every 6 hours by transrectal ultrasonography until ovulation. The interval between prostaglandin administration and ovulation was lower (P < .05) in jennies from the G1 (145.2 ± 34.6 hours) and G2 (147.4 ± 27.3 hours) groups compared with the control cycle (220.0 ± 41.8 hours). Both treatments (G1, 41.15 ± 3.5 hours; G2, 37.8 ± 2.5 hours) also reduced (P < .05) the interval that jennies took to ovulate after the administration of the ovulation-inducing agent compared with the control (81.8 ± 28.8 hours). All jennies from G1 and G2 ovulated up to 48 hours after ovulation induction, whereas 100% of jennies in the control cycle ovulated later (>48 hours from the administration of saline). In conclusion, both histrelin acetate and hCG at the used dose are efficient ovulation-inducing agents in jennies promoting ovulation up to 48 hours after administration.
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Affiliation(s)
- Sidnei N Oliveira
- Sao Paulo State University (Unesp), School of Veterinary Medicine and Animal Science, Botucatu, Brazil.
| | - Lorenzo G T M Segabinazzi
- Sao Paulo State University (Unesp), School of Veterinary Medicine and Animal Science, Botucatu, Brazil
| | - Lucas Canuto
- Sao Paulo State University (Unesp), School of Veterinary Medicine and Animal Science, Botucatu, Brazil
| | | | - Felipe E Medrado
- Sao Paulo State University (Unesp), School of Veterinary Medicine and Animal Science, Botucatu, Brazil
| | - Jose A Dell'Aqua
- Sao Paulo State University (Unesp), School of Veterinary Medicine and Animal Science, Botucatu, Brazil
| | - Antonio J A Aguiar
- Sao Paulo State University (Unesp), School of Veterinary Medicine and Animal Science, Botucatu, Brazil
| | - Frederico O Papa
- Sao Paulo State University (Unesp), School of Veterinary Medicine and Animal Science, Botucatu, Brazil
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43
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Equivalent live-birth rate in antagonist IVF/ICSI protocol after oocyte triggering with GnRH agonist supplemented with 1500 r-hCG the day of oocyte retrieval vs r-hCG : A case-control study. J Gynecol Obstet Hum Reprod 2020; 49:101702. [DOI: 10.1016/j.jogoh.2020.101702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 01/26/2020] [Accepted: 01/29/2020] [Indexed: 11/17/2022]
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44
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Mohr-Sasson A, Orvieto R, Blumenfeld S, Axelrod M, Mor-Hadar D, Grin L, Aizer A, Haas J. The association between follicle size and oocyte development as a function of final follicular maturation triggering. Reprod Biomed Online 2020; 40:887-893. [DOI: 10.1016/j.rbmo.2020.02.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 02/05/2020] [Accepted: 02/11/2020] [Indexed: 11/26/2022]
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45
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Racca A, Drakopoulos P, Neves AR, Polyzos NP. Current Therapeutic Options for Controlled Ovarian Stimulation in Assisted Reproductive Technology. Drugs 2020; 80:973-994. [DOI: 10.1007/s40265-020-01324-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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46
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Abdelhakim AM, Abd-ElGawad M, Hussein RS, Abbas AM. Vaginal versus intramuscular progesterone for luteal phase support in assisted reproductive techniques: a systematic review and meta-analysis of randomized controlled trials. Gynecol Endocrinol 2020; 36:389-397. [PMID: 32054365 DOI: 10.1080/09513590.2020.1727879] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
We aimed to compare the efficacy of vaginal progesterone versus intramuscular progesterone (IMP) for luteal phase support in assisted reproductive techniques (ART). A comprehensive electronic search of four electronic databases (PubMed, Cochrane Library, Scopus, and ISI Web of Science) was performed from inception till August 2019 for randomized controlled trials (RCTs). We included studies performed different ART with the use of vaginal progesterone versus IMP for luteal phase support. Our primary outcome was clinical pregnancy rate. Our secondary outcomes were ongoing pregnancy, miscarriage, live birth rates, and satisfaction in both groups. 15 RCTs met our inclusion criteria with a total of 5656 patients. Our analysis indicated no significant differences between vaginal progesterone and IMP regarding clinical and ongoing pregnancies (RR = 0.90, 95% CI [0.80, 1.00], p = .06), (RR = 0.90, 95% CI [0.76, 1.06], p = .21), respectively. No significant differences were found between both routes of progesterone in miscarriage (p = .98) and live birth (p = .99). Subgroup analysis between fresh and frozen embryo transfer cycles in above outcomes showed no difference between progesterone routes. Vaginal progesterone was significantly associated with more satisfaction compared to IMP (p < .00001). In conclusion, vaginal progesterone can be used an alternative method for luteal phase support instead of IMP in ART.
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Affiliation(s)
- Ahmed Mohamed Abdelhakim
- Medical Research Group of Egypt, Cairo, Egypt
- Kasralainy, Faculty of medicine, Cairo University, Cairo, Egypt
| | - Mohamed Abd-ElGawad
- Medical Research Group of Egypt, Cairo, Egypt
- Faculty of medicine, Fayoum University, Fayoum, Egypt
| | - Reda S Hussein
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Egypt
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA
| | - Ahmed M Abbas
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Egypt
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47
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Castillo JC, Haahr T, Martínez-Moya M, Humaidan P. Gonadotropin-releasing hormone agonist ovulation trigger-beyond OHSS prevention. Ups J Med Sci 2020; 125:138-143. [PMID: 32208810 PMCID: PMC7721031 DOI: 10.1080/03009734.2020.1737599] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
In this review the advantages of the gonadotropin-releasing hormone agonist (GnRHa) trigger are discussed beyond those immediately associated with ovarian hyperstimulation syndrome (OHSS) prevention. The GnRHa trigger concept has sparked the development of novel protocols, enriching the assisted reproductive technology (ART) armamentarium for the benefit of present and future patients. Thus, GnRHa trigger already has a pivotal role, not only for the standard in vitro fertilisation (IVF) patient, but also for patient groups like oocyte donors, cancer patients, patients with poor ovarian reserve, and patients with immature oocyte syndrome and empty follicle syndrome. Herein, we discuss the importance of the GnRHa-elicited midcycle FSH surge and the potential improvement in oocyte yield and embryo competence.
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Affiliation(s)
- Juan Carlos Castillo
- Department of Human Assisted Reproduction, Instituto Bernabeu, Alicante, Spain
- CONTACT Juan Carlos Castillo Department of Human Assisted Reproduction, Instituto Bernabeu, Av. Albufereta 31, 03016Alicante, Spain
| | - Thor Haahr
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- The Fertility Clinic Skive, Skive Regional Hospital, Skive, Denmark
| | - María Martínez-Moya
- Department of Human Assisted Reproduction, Instituto Bernabeu, Alicante, Spain
| | - Peter Humaidan
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- The Fertility Clinic Skive, Skive Regional Hospital, Skive, Denmark
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48
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Jones BP, Al-Chami A, Gonzalez X, Arshad F, Green J, Bracewell-Milnes T, Saso S, Smith R, Serhal P, Ben Nagi J. Is oocyte maturity influenced by ovulation trigger type in oocyte donation cycles? HUM FERTIL 2019; 24:360-366. [PMID: 31571498 DOI: 10.1080/14647273.2019.1671614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The aim of this study was to compare clinical and laboratory outcomes between GnRHa, dual and HCG triggers in altruistic oocyte donation cycles. Normal or high responders were given either gonadotropin releasing hormone agonist (GnRHa) or a dual trigger of GnRHa and a low dose of human chorionic gonadotropin (HCG). Low responders were given HCG trigger. In 333 cycles, 232 (69.7%) received GnRHa trigger, 59 (17.7%) received dual trigger and 42 (12.6%) had HCG trigger. The total number of mature oocytes retrieved and cryopreserved were significantly higher in the GnRHa and dual trigger groups, compared to the HCG group (p < 0.001). However, the ovarian hyperstimulation syndrome (OHSS) rate was significantly higher in the dual trigger group (n = 5 (8.5%)), compared to the GnRH agonist (n = 1 (0.4%)) and HCG groups (n = 0 (0%)) (p = 0.001). GnRHa trigger maximises mature oocyte yields in oocyte donors suspected of normal and high response but offers a significant reduction in OHSS risk compared to dual trigger. As such, dual trigger should not be used in oocyte donation. HCG trigger can also be used with a very low risk of OHSS at low risk of OHSS in carefully selected donors where GnRHa is unlikely to be effective.
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Affiliation(s)
- Benjamin P Jones
- Department of Gynaecology, Hammersmith Hospital, Imperial College NHS Trust , London , UK.,Department of Surgery and Cancer, Imperial College London , London , UK
| | - Ali Al-Chami
- Centre for Reproductive and Genetic Health , London , UK
| | | | - Falak Arshad
- Centre for Reproductive and Genetic Health , London , UK
| | - Joy Green
- Centre for Reproductive and Genetic Health , London , UK
| | | | - Srdjan Saso
- Department of Gynaecology, Hammersmith Hospital, Imperial College NHS Trust , London , UK.,Department of Surgery and Cancer, Imperial College London , London , UK
| | - Richard Smith
- Department of Gynaecology, Hammersmith Hospital, Imperial College NHS Trust , London , UK.,Department of Surgery and Cancer, Imperial College London , London , UK
| | - Paul Serhal
- Centre for Reproductive and Genetic Health , London , UK
| | - Jara Ben Nagi
- Centre for Reproductive and Genetic Health , London , UK
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49
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Poulsen LLC, Pla I, Sanchez A, Grøndahl ML, Marko-Varga G, Yding Andersen C, Englund ALM, Malm J. Progressive changes in human follicular fluid composition over the course of ovulation: quantitative proteomic analyses. Mol Cell Endocrinol 2019; 495:110522. [PMID: 31356852 DOI: 10.1016/j.mce.2019.110522] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 06/17/2019] [Accepted: 07/24/2019] [Indexed: 12/12/2022]
Abstract
Follicular fluid (FF) acts as a vehicle for paracrine signalling between somatic cells of the follicle and the oocyte. To investigate changes in the protein composition of FF during ovulation, we conducted a prospective cohort study including 25 women undergoing fertility treatment. Follicular fluid was aspirated either before or 12, 17, 32 or 36 h after induction of ovulation (five patients per time point). Liquid chromatography-mass spectrometry was used to identify and quantify FF proteins. In total, 400 proteins were identified and the levels of 40 proteins changed significantly across ovulation, evaluated by analysis of covariance (adjusted p < 0.05) and on-off expression patterns. The majority peaked after 12-17 h, e.g., AREG (p < 0.0001), TNFAIP6 (p < 0.0001), and LDHB (p = 0.0316), while some increased to peak after 36 h e.g., ACPP (p < 0.0001), TIMP1 (p < 0.0001) and SERPINE1 (p = 0.0002). Collectively, this study highlights proteins and pathways of importance for ovulation and oocyte competence in humans.
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Affiliation(s)
- Liv la Cour Poulsen
- Zealand Fertility Clinic, Zealand University Hospital, Lykkebækvej 14, 4600 Køge, Denmark.
| | - Indira Pla
- Clinical Protein Science & Imaging, Biomedical Centre, Department of Biomedical Engineering, Lund University, BMC D13, 221 84 Lund, Sweden; Section for Clinical Chemistry, Department of Translational Medicine, Lund University, Skåne University Hospital Malmö, 205 02 Malmö, Sweden
| | - Aniel Sanchez
- Clinical Protein Science & Imaging, Biomedical Centre, Department of Biomedical Engineering, Lund University, BMC D13, 221 84 Lund, Sweden; Section for Clinical Chemistry, Department of Translational Medicine, Lund University, Skåne University Hospital Malmö, 205 02 Malmö, Sweden
| | - Marie Louise Grøndahl
- Fertility Clinic, University Hospital of Copenhagen, Herlev and Gentofte Hospital, Herlev Ringvej 75, 2730 Herlev, Denmark
| | - György Marko-Varga
- Clinical Protein Science & Imaging, Biomedical Centre, Department of Biomedical Engineering, Lund University, BMC D13, 221 84 Lund, Sweden; Section for Clinical Chemistry, Department of Translational Medicine, Lund University, Skåne University Hospital Malmö, 205 02 Malmö, Sweden; Department of Surgery, Tokyo Medical University, 6-7-1 Nishishinjiku Shinjiku-ku, Japan
| | - Claus Yding Andersen
- Laboratory of Reproductive Biology, University Hospital of Copenhagen, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | | | - Johan Malm
- Clinical Protein Science & Imaging, Biomedical Centre, Department of Biomedical Engineering, Lund University, BMC D13, 221 84 Lund, Sweden; Section for Clinical Chemistry, Department of Translational Medicine, Lund University, Skåne University Hospital Malmö, 205 02 Malmö, Sweden
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50
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Evaluation of uterine receptivity after gonadotropin releasing hormone agonist administration as an oocyte maturation trigger: a rodent model. Sci Rep 2019; 9:12519. [PMID: 31467307 PMCID: PMC6715633 DOI: 10.1038/s41598-019-48918-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 08/12/2019] [Indexed: 01/16/2023] Open
Abstract
In natural cycle or minimal stimulation cycle IVF, buserelin acetate (buserelin), a gonadotropin-releasing hormone agonist, is often used as a maturation trigger; however, its effect on pregnancy outcomes remains unclear. Therefore, in the present study, we compared uterine receptivity in buserelin-administered mice with that in human chorionic gonadotropin (hCG)-administered mice during the peri-implantation period. Implantation, decidualisation, and term-pregnancy were impaired following hCG, but not buserelin administration. hCG stimulated the synthesis and secretion of progesterone and oestradiol, whereas ovarian steroidogenesis in the buserelin-treated group was comparable with that in the control group. Furthermore, similar to the observation in controls, the buserelin-treated group exhibited activation of progesterone receptor signalling and inhibition of oestrogen receptor signalling in the endometrial epithelium on the day of implantation. However, epithelial progesterone signalling was not detected, and a high expression of genes downstream to oestrogen was observed on day 4 following hCG administration. These results suggest that buserelin administration does not impact uterine receptivity as it did not affect ovarian steroidogenesis and endometrial steroid signalling. Therefore, buserelin is preferred as an oocyte maturation trigger to optimise uterine receptivity during treatments involving timed intercourse, intrauterine insemination, or fresh embryo transfer following in vitro fertilisation.
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