Comparative Effectiveness of Three Ovarian Hyperstimulation Protocol in In Vitro Fertilization (IVF) Cycles for Women with Polycystic Ovary Syndrome

Factors affecting cumulative live birth rate after the 1st oocyte retrieved in polycystic ovary syndrome patients in women during IVF/ICSI-ET

BACKGROUND

The factors affecting the cumulative live birth rate (CLBR) of PCOS (Polycystic ovary syndrom) patients who received in vitro fertilization/intracytoplasmic sperm injection-embryo transfer (IVF/ICSI-ET) needs more research for a better outcome.

METHODS

Here we carried out a retrospective analysis of 1380 PCOS patients who received IVF/ICSI-ET for the first time from January 2014 to December 2016. We divided them into cumulative live birth group (group A) and non-cumulative live birth group (group B) according to whether there were live births.

RESULTS

The conservative cumulative live birth rate was 63.48%. There were 876 cumulative live births (group A) and 504 non-cumulative live births (group B) according to whether the patients had live births or not. Competition analysis showed that duration of infertility, primary/secondary type of infertility, stimulation protocols, starting dose of gonadotrophins and oocyte retrieved numbers were significantly correlated with CLBR. The Cox proportional risk regression model of PCOS patients showed that stimulation protocols had a significant impact on CLBR. Patients in the GnRH (Gonadotropin-releasing hormone)-antagonist protocol group and the mild stimulation protocol had lower CLBR than those in the prolonged GnRH-agonist protocol, which was statistically significant. PCOS patients with the starting dose of gonadotrophins greater than 112.5u had lower CLBR than those with less than 100u, which was statistically significant. Women with 11-15 oocytes and 16-20 oocytes had higher CLBR than women with 1-9 oocytes, which was statistically significant.

CONCLUSIONS

When we used Prolonged GnRH-agonist protocol, or the first starting dose of gonadotrophins was 100u-112.5u, or the number of oocytes obtained was 11-15 and 16-20, the CLBR of PCOS patients increased significantly after the 1st oocyte collection.

Pregnancy outcome in long- versus short-acting gonadotropin-releasing hormone agonist cycles in participants with normal ovarian reserve: An RCT

Background

There is no agreement on which of the 2 gonadotropin-releasing hormone (GnRH) agonist protocols are the most efficient, neither there is any consensus on which one yields a better clinical pregnancy percentage.

Objective

The present study aims to compare the effectiveness of reduced dosages of long- and short-acting GnRH agonists on pregnancy outcomes.

Materials and Methods

In this randomized controlled clinical trial, 400 women were randomly assigned to 2 groups (n = 200/group): the reduced dosage of long-acting GnRH agonist group (group 1, 1.25 mg Decapeptyl) and the short-acting GnRH agonist group (group 2, 0.5 mg/day Buserelin Acetate). The study was conducted at Mehr Medical Institute, Rasht, Iran between July 2019 and July 2020. Biochemical and clinical pregnancy were compared between groups.

Results

No significant differences were observed in the endometrial lining, the total number of retrieved and metaphase-II oocytes, progesterone, and serum estradiol levels on human chorionic gonadotropin day, fertilization rate, and top-quality embryos between the groups. The duration of induction (10.8 ± 1.7 vs. 10 ± 2.1, p < 0.001) and the total dosage of gonadotropins (2939.4 ± 945.9 vs. 2441 ± 1247.1, p < 0.001) were significantly greater in group 2 than in group 1. No significant differences were observed between the 2 groups in terms of implantation rate, chemical pregnancy rate, and clinical pregnancy rate. A higher percentage of ovarian hyperstimulation syndrome was observed in group 2 (p = 0.005).

Conclusion

Due to a lower percentage of ovarian hyperstimulation syndrome in group 1 and similar assisted reproductive technology outcomes in both groups, the long protocol was found to be superior to the short protocol.

Is early-follicular long-acting GnRH agonist protocol an alternative for patients with polycystic ovary syndrome undergoing in vitro fertilization?

BACKGROUND

We aimed to compare the clinical and perinatal outcomes of patients with polycystic ovary syndrome (PCOS) undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatment with either an early-follicular long-acting gonadotropin-releasing hormone agonist (GnRH-a) long protocol (EFLL) or a midluteal short-acting GnRH-a long protocol (MLSL).

METHODS

This single-center, retrospective study, included patients with PCOS who underwent IVF/ICSI from January 2013 to June 2019 at the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China. Patients underwent either MLSL (1179 cycles) or EFLL (2390 cycles). The primary outcomes were pregnancy outcomes, perinatal and maternal complications.

RESULTS

Fresh embryo transfer (59.12% vs. 55.47%, P = 0.038), clinical pregnancy (75.23% vs. 53.82%, P = 0.001), and live birth rates (63.27% vs. 42.05%, P = 0.010) were higher in the EFLL group. However, the proportion of patients "freezing all" for high risk of ovarian hyperstimulation syndrome (OHSS) (24.27% vs. 32.06%, P = 0.001) and ectopic pregnancy (1.51% vs. 5.97%, P = 0.002) were lower in the EFLL group than in the MLSL group. The incidence of gestational diabetes was higher in the EFLL group than in the MLSL group (5.08% vs. 1.42%, RR 3.714, 95% confidence interval (CI) 1.474-9.360, P = 0.003). There were no significant differences in the incidence of hypertension, premature rupture of membranes, placenta previa, congenital heart disease, or neonatal weight between the two groups. Logistic regression results showed that age (OR 0.966, 95% CI 0.941-0.993, P = 0.013), treatments (OR 2.380, 95% CI 1.833-3.089, P = 0.001), and endometrial thickness on trigger day (OR 1.115, 95% CI 1.070-1.162, P = 0.001) were correlated with clinical pregnancy. Pre-pregnancy BMI (OR 1.098, 95% CI 1.002-1.204, P = 0.046), fasting plasma glucose (FPG) (OR 3.096, 95% CI 1.900-5.046, P = 0.001), and treatments (OR 3.458, 95% CI 1.359-8.800, P = 0.009) were correlated with gestational diabetes mellitus (GDM). Treatments (OR 0.291, 95% CI 0.148-0.575, P = 0.001) and endometrial thickness on trigger day (OR 0.834, 95% CI 0.722-0.962, P = 0.013) were correlated with ectopic pregnancy.

CONCLUSION

The early-follicular long-acting GnRH agonist long protocol can be used as an ideal assisted reproductive technology (ART) pregnancy assistance program for patients with PCOS, but obese patients should be encouraged to lose weight before ART treatments to reduce the risk of GDM.

Conventional GnRH antagonist protocols versus long GnRH agonist protocol in IVF/ICSI cycles of polycystic ovary syndrome women: a systematic review and meta-analysis

Gonadotropin-releasing hormone (GnRH) analogues are commonly used in clinical practice to prevent premature luteinizing hormone (LH) surge during In-Vitro Fertilization/ Intra-Cytoplasmic Sperm Injection (IVF/ICSI) cycles. This review aimed to summarize the available evidence comparing the effects of conventional GnRH antagonist protocols, the most commonly used GnRH antagonist protocols, and GnRH agonist protocols on IVF/ICSI outcomes in women with polycystic ovary syndrome (PCOS). A comprehensive electronic search was carried out in Pubmed, Cochrane CENTRAL, Scopus, Web of Science, CINAHL, TRIP, ClinicalTrials.gov and ISRCTN registry from inception until 24 November 2020 without any language or date restrictions. In addition, reference lists of eligible studies and previous meta-analyses were hand-searched to identify relevant studies. Eligible randomized controlled trials were those designed to compare the effects of conventional GnRH antagonist protocols and GnRH agonist protocols on IVF/ICSI outcomes in PCOS subjects. The Cochrane ROB 2.0 tool was used to assess the risk of bias of each study, and the GRADE assessment was used to evaluate the overall quality of evidence. Data synthesis and analyses were done using Review Manager 5.3 with the assistance of Revman Web. A random-effects model was used for all meta-analysis. Dichotomous outcomes were reported as Relative Risk (RR) and continuous outcomes as Weighted Mean Difference (WMD), both with 95% CIs. The primary outcomes were Live birth rate, Ongoing pregnancy rate, and Ovarian hyperstimulation syndrome (OHSS) rate. Other IVF outcomes were considered secondary outcomes. We included ten studies with 1214 randomized PCOS women. Using GnRH antagonist protocols led to a significantly lower OHSS rate (RR = 0.58; 95% CI: [0.44 to 0.77], P = 0.0002), shorter stimulation duration (WMD = - 0.91; 95% CI: [-1.45 to - 0.37] day, P = 0.0009), lower gonadotropin consumption (WMD = - 221.36; 95% CI: [- 332.28 to - 110.45] IU, P < 0.0001), lower E2 levels on hCG day (WMD = - 259.21; 95% CI: [- 485.81 to - 32.60] pg/ml, P = 0.02), thinner endometrial thickness on hCG day (WMD = - 0.73; 95% CI: [- 1.17 to - 0.29] mm, P = 0.001), and lower number of retrieved oocytes (WMD = - 1.82; 95% CI: [- 3.48 to - 0.15] oocytes, P = 0.03). However, no significant differences in live birth rate, ongoing pregnancy rate, clinical pregnancy rate, multiple pregnancy rate, miscarriage rate and cycle cancellation rate were seen between the GnRH antagonist protocols and the long GnRH agonist one. Although more cycles were cancelled due to poor ovarian response in the GnRH antagonist protocol (RR = 4.63; 95% CI: [1.49 to 14.41], P = 0.008), similar rates of cancellation due to risk of OHSS were noticed in both groups. The differences in IVF/ICSI outcomes may arise from the different patterns of gonadotropins suppression that the GnRH analogues exhibit during the early follicular phase of IVF/ICSI cycles and the divergent direct impacts of these analogues on ovaries and endometrial receptivity. The main evidence limitation was Imprecision. Conventional GnRH antagonist protocols represent a safer and more cost-effective treatment choice for PCOS women undergoing IVF/ICSI cycles than the standard long GnRH agonist protocol without compromising the IVF/ICSI clinical outcomes. The study had no sources of financial support and was prospectively registered at PROSPERO (International Prospective Register of Systematic Reviews) under registration number (CRD42021242476).

Metabolic alterations associated with polycystic ovary syndrome: A UPLC Q-Exactive based metabolomic study

BACKGROUND

The polycystic ovary syndrome (PCOS) is the most common endocrine and metabolic disorder syndrome of women in reproductive age. Metabolomic studies of the follicular fluid can reveal the potential metabolic pathways related to PCOS. The objection of this study was to explore the changes of metabolites in the follicular fluid of PCOS.

METHODS

We collected follicular fluid samples of 35 patients with PCOS and 33 controls without PCOS for metabolomic analysis with UPLC Q-Exactive. The identified metabolites were annotated with KEGG and HMDB to determine the disturbances of metabolic pathways in PCOS. Based on the regression model, we conducted the ROC analysis to find the biomarker of PCOS in the follicular fluid.

RESULTS

Metabolomic analysis identified 21 differential metabolites in PCOS, which revealed that the Vitamin B6 metabolism, phenylalanine metabolism and carnitine synthesis were the key changed pathways. We found that 7β-Hydroxycholesterol was potential biomarker of PCOS based on the ROC analysis.

CONCLUSION

We identified metabolic alterations and biomarker in the follicular fluid of PCOS, providing novel ways for the diagnosis and treatment of PCOS.