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Spring S, Tsai S, Verzani Z, Spandorfer S. Limiting the number of fresh donor oocytes inseminated with sperm as a strategy to minimize supernumerary embryos. Fertil Steril 2024:S0015-0282(24)00632-0. [PMID: 39117172 DOI: 10.1016/j.fertnstert.2024.07.035] [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: 03/13/2024] [Revised: 07/23/2024] [Accepted: 07/24/2024] [Indexed: 08/10/2024]
Abstract
OBJECTIVE To determine the optimal number of fresh donor oocytes to expose to sperm for patients who want to prioritize reducing surplus embryos while preserving the live birth rate. DESIGN Cross-sectional study. SETTING University. PATIENT(S) Patients who underwent their first in vitro fertilization of fresh donor oocytes at a single academic institution between January 2013 and November 2022. Patients were excluded if they used a directed oocyte donor, donor aged >32 years, gestational carrier, surgically retrieved sperm, or preimplantation genetic testing. INTERVENTION(S) Number of fresh mature donor oocytes fertilized via intracytoplasmic sperm injection. MAIN OUTCOME MEASURE(S) The primary outcome was the number of cryopreserved supernumerary blastocysts. The number of supernumerary blastocysts was defined as the number of blastocysts remaining after the first live birth, or if the patient did not have a live birth, the number of supernumerary blastocysts was determined by the number of blastocysts remaining after the last transfer cycle. The Kruskal-Wallis rank sum test was used to determine differences in number of supernumerary blastocysts. RESULT(S) A total of 543 patients who underwent 750 embryo transfer cycles using fresh donor oocytes were included. The average recipient age was 42.9 ± 3.8 years, and the average oocyte donor age was 26.6 ± 3.0 years. For our cohort, patients received a median of 10 (interquartile range [IQR], 8-14) mature donor oocytes; 8 (IQR, 6-11) were injected with sperm, 4 (IQR, 3-6) usable embryos were developed, and 2 (IQR, 0-5) supernumerary blastocysts remained. Patients were then divided into four quartiles on the basis of the number of mature donor oocytes received (≤7, 8-10, 11-14, or ≥15). There was a significant increase in the median number of cryopreserved supernumerary blastocysts as the number of mature donor oocytes exposed to sperm increased (1 vs. 2 vs. 3 vs. 6 blastocysts in the first, second, third, and fourth quartiles, respectively). There were no statistically significant differences in live birth rates between the quartiles. CONCLUSION(S) The number of supernumerary blastocysts significantly increased as more mature donor oocytes were exposed to sperm. This study can serve as a counseling tool for patients with concerns regarding excess cryopreserved embryos when using fresh donor oocytes.
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Affiliation(s)
- Samantha Spring
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, New York.
| | - Shelun Tsai
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, New York
| | - Zoe Verzani
- Weill Cornell Medicine Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Steven Spandorfer
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, New York
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Svenstrup L, Möller S, Fedder J, Pedersen DE, Erb K, Andersen CY, Humaidan P. Investigation of luteal HCG supplementation in GnRH-agonist-triggered fresh embryo transfer cycles: a randomized controlled trial. Reprod Biomed Online 2024; 48:103415. [PMID: 38452605 DOI: 10.1016/j.rbmo.2023.103415] [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: 05/01/2023] [Revised: 08/14/2023] [Accepted: 09/14/2023] [Indexed: 03/09/2024]
Abstract
RESEARCH QUESTION Does splitting the human chorionic gonadotrophin (HCG) support in IVF cycles triggered by a gonadotrophin-releasing hormone agonist result in a better progesterone profile? DESIGN Randomized controlled three-arm study, performed at the Fertility Clinic, Odense University Hospital, Denmark. Patients with 12-25 follicles ≥12 mm were randomized into three groups: Group 1 - ovulation triggered with 6500 IU HCG; Group 2 - ovulation triggered with 0.5 mg GnRH agonist, followed by 1500 IU HCG on the day of oocyte retrieval (OCR); and Group 3 - ovulation triggered with 0.5 mg GnRH agonist, followed by 1000 IU HCG on the day of OCR and 500 IU HCG on OCR + 5. All groups received 180 mg vaginal progesterone. Progesterone concentrations were analysed in eight blood samples from each patient. RESULTS Sixty-nine patients completed the study. Baseline and laboratory data were comparable. Progesterone concentration peaked on OCR + 4 in Groups 1 and 2, and peaked on OCR + 6 in Group 3. On OCR + 6, the progesterone concentration in Group 2 was significantly lower compared with Groups 1 and 3 (P = 0.003 and P < 0.001, respectively). On OCR + 8, the progesterone concentration in Group 3 was significantly higher compared with the other groups (both P<0.001). Progesterone concentrations were significantly higher in Group 3 from OCR + 6 until OCR + 14 compared with the other groups (all P ≤ 0.003). Four patients developed ovarian hyperstimulation syndrome in Group 3. CONCLUSION Sequential HCG support after a GnRH agonist trigger provides a better progesterone concentration in the luteal phase.
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Affiliation(s)
- Louise Svenstrup
- Faculty of Health Sciences, Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Research Unit of Gynaecology and Obstetrics, Odense University Hospital, Odense, Denmark; Fertility Clinic, Unit of Gynaecology and Obstetrics, Odense University Hospital, Odense, Denmark.
| | - Sören Möller
- Faculty of Health Sciences, Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Open Patient Data Explorative Network, Odense University Hospital, Odense, Denmark
| | - Jens Fedder
- Faculty of Health Sciences, Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Research Unit of Gynaecology and Obstetrics, Odense University Hospital, Odense, Denmark; Fertility Clinic, Unit of Gynaecology and Obstetrics, Odense University Hospital, Odense, Denmark
| | - Dorrit Elschner Pedersen
- Fertility Clinic, Unit of Gynaecology and Obstetrics, Odense University Hospital, Odense, Denmark
| | - Karin Erb
- Fertility Clinic, Unit of Gynaecology and Obstetrics, Odense University Hospital, Odense, Denmark
| | - Claus Yding Andersen
- Laboratory of Reproductive Biology, The Juliane Marie Centre for Women, Children and Reproduction, University Hospital of Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Peter Humaidan
- Faculty of Health Sciences, Department of Clinical Research, University of Southern Denmark, Odense, Denmark; The Fertility Clinic, Skive Regional Hospital, Skive, Denmark; Faculty of Health, Institute for Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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Prevention of moderate and severe ovarian hyperstimulation syndrome: a guideline. Fertil Steril 2024; 121:230-245. [PMID: 38099867 DOI: 10.1016/j.fertnstert.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 11/14/2023] [Indexed: 02/05/2024]
Abstract
Ovarian hyperstimulation syndrome is a serious complication associated with assisted reproductive technology. This systematic review aims to identify who is at high risk for developing ovarian hyperstimulation syndrome, along with evidence-based strategies to prevent it and replaces the document of the same name last published in 2016.
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Pollie MP, Romanski PA, Bortoletto P, Spandorfer SD. Combining early pregnancy bleeding with ultrasound measurements to assess spontaneous abortion risk among infertile patients. Am J Obstet Gynecol 2023; 229:534.e1-534.e10. [PMID: 37487856 DOI: 10.1016/j.ajog.2023.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 07/04/2023] [Accepted: 07/16/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Approximately 15% of all clinically recognized pregnancies in patients with infertility result in spontaneous abortion. However, despite its potential to have a profound and lasting effect on physical and emotional well-being, the natural history of spontaneous abortion in women with infertility has not been described. Although vaginal bleeding is a common symptom in pregnancies conceived via reproductive technologies, its prognostic value is not well understood. OBJECTIVE This study aimed to evaluate the combination of early pregnancy bleeding and first-trimester ultrasound measurements to determine spontaneous abortion risk. STUDY DESIGN This was a retrospective cohort study of patients with infertility who underwent autologous embryo transfer resulting in singleton intrauterine pregnancy confirmed by ultrasound from January 1, 2017, to December 31, 2019. Early pregnancy symptoms of bleeding occurring before gestational week 8 and measurements of crown-rump length and fetal heart rate from ultrasounds performed during gestational week 6 (6 0/7 to 6 6/7 weeks of gestation) and gestational week 7 (7 0/7 to 7 6/7 weeks of gestation) were recorded. Modified Poisson regression with robust error variance was adjusted a priori for patient age, embryo transfer day, and transfer of a preimplantation genetic-tested embryo to estimate the relative risk and 95% confidence interval of spontaneous abortion for dichotomous variables. The relative risks and positive predictive values for early pregnancy bleeding combined with ultrasound measurements on the occurrence of spontaneous abortion were calculated for patients who had an ultrasound performed during gestational week 6 and separately for patients who had an ultrasound performed during gestational week 7. The primary outcome was spontaneous abortion in the setting of vaginal bleeding with normal ultrasound parameters. The secondary outcomes were spontaneous abortion with vaginal bleeding and (1) abnormal crown-rump length, (2) abnormal fetal heart rate, and (3) both abnormal crown-rump length and abnormal fetal heart rate. RESULTS Of the 1858 patients who were included (359 cases resulted in abortions and 1499 resulted in live births), 315 patients (17.0%) reported vaginal bleeding. When combined with ultrasound measurements from gestational week 6, bleeding was significantly associated with increased spontaneous abortion only when accompanied by absent fetal heart rate (relative risk, 5.36; 95% confidence interval, 3.36-8.55) or both absent fetal heart rate and absent fetal pole (relative risk, 9.67; 95% confidence interval, 7.45-12.56). Similarly, when combined with ultrasound measurements from gestational week 7, bleeding was significantly associated with increased spontaneous abortion only when accompanied by an abnormal assessment of fetal heart rate or crown-rump length (relative risk, 5.09; 95% confidence interval, 1.83-14.19) or both fetal heart rate and crown-rump length (relative risk, 14.82; 95% confidence interval, 10.54-20.83). With normal ultrasound measurements, bleeding was not associated with increased spontaneous abortion risk (relative risk: 1.05 [95% confidence interval, 0.61-1.78] in gestational week 6 and 0.80 [95% confidence interval, 0.36-1.74] in gestational week 7), and the live birth rate was comparable with that in patients with normal ultrasound measurements and no bleeding. CONCLUSION Patients with a history of infertility who present after embryo transfer with symptoms of vaginal bleeding should be evaluated with a pregnancy ultrasound to accurately assess spontaneous abortion risk. In the setting of normal ultrasound measurements, patients can be reassured that their risk of spontaneous abortion is not increased and that their live birth rate is not decreased.
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Affiliation(s)
| | - Phillip A Romanski
- Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, NY
| | - Pietro Bortoletto
- Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, NY
| | - Steven D Spandorfer
- Weill Cornell Medical College, Cornell University, New York, NY; Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, NY
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Tsai S, Johal J, Malmsten J, Spandorfer S. Embryo ploidy in vitrified versus fresh oocytes: Is there a difference? J Assist Reprod Genet 2023; 40:2419-2425. [PMID: 37566316 PMCID: PMC10504137 DOI: 10.1007/s10815-023-02901-0] [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: 05/15/2023] [Accepted: 07/25/2023] [Indexed: 08/12/2023] Open
Abstract
PURPOSE To evaluate embryo ploidy in a cohort of patients who underwent preimplantation genetic testing for aneuploidy (PGT-A) with vitrified oocytes compared to fresh oocytes. METHODS Patients who underwent their first autologous oocyte vitrification and warming followed by in vitro fertilization (IVF) and trophectoderm biopsy for PGT-A between 1/1/2017 and 12/31/2021 at a single academic institution were included. Patients were compared 1:3 to age-matched controls who underwent their first IVF cycle with fresh oocytes and subsequent trophectoderm biopsy for PGT-A. The primary outcome was the proportions of euploid, mosaic, and aneuploid embryos between those using vitrified versus fresh oocytes. RESULTS 117 patients who cryopreserved a total of 1,272 mature oocytes were included in the study and were matched with 351 controls using fresh oocytes. The average age was 36.9 ± 2.6 years, and the median interval between oocyte vitrification and warming was 38 months. There were similar numbers of mature oocytes (10.9 ± 4.9 vs. 11.1 ± 6.3, P = .67), fertilized oocytes (7.8 ± 4.0 vs. 8.7 ± 5.5, P = .10), and blastocysts per patient (5.1 ± 3.1 vs. 5.8 ± 4.3, P = .10) between those using vitrified versus fresh oocytes. In terms of embryo ploidy results, there were no statistically significant differences in rates of euploidy (40.1% vs. 41.6%), mosaicism (15.7% vs. 12.0%), or aneuploidy (44.3% vs. 46.4%) (P = .06) between the two groups. CONCLUSIONS Oocyte vitrification with subsequent warming, fertilization, and trophectoderm biopsy for PGT-A was not associated with adverse chromosomal competence when compared to age-matched controls utilizing fresh oocytes.
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Affiliation(s)
- Shelun Tsai
- Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, 1305 York Avenue 6th Floor, New York, NY, 10021, USA.
| | - Jasmyn Johal
- Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, 1305 York Avenue 6th Floor, New York, NY, 10021, USA
| | - Jonas Malmsten
- Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, 1305 York Avenue 6th Floor, New York, NY, 10021, USA
| | - Steven Spandorfer
- Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, 1305 York Avenue 6th Floor, New York, NY, 10021, USA
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Wiweko B, Surya E, Silvana V, Maidarti M, Kemal Harzif A, Pratama G, Sumapraja K, Muharam R, Hestiantoro A. Twelve Hours Post-Injection Serum Human Chorionic Gonadotropin and Body Mass Index Predicts In Vitro Fertilization Oocyte Maturation Rate: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF FERTILITY & STERILITY 2023; 17:264-267. [PMID: 37577910 PMCID: PMC10439995 DOI: 10.22074/ijfs.2023.555467.1315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 11/17/2022] [Accepted: 01/09/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND In vitro fertilization (IVF) remains a main treatment for infertility cases. Post-injection human chorionic gonadotropin (hCG) level is an essential factor in determining oocyte maturation rate in IVF. This study aimed to determine the relationship between 12 hours post-injection serum hCG level and oocyte maturation rate among IVF participants. MATERIALS AND METHODS A cross-sectional study on IVF participants was done at a tertiary hospital in Indonesia from January 2020 to December 2021. Subjects were injected with 250 μg of recombinant-hCG (r-hCG) subcutaneously. Twelve hours post-injection serum hCG levels and oocyte maturation rate data were retrieved and analyzed accordingly. RESULTS Twenty-eight subjects were recruited into the study. Higher 12 hours post-injection serum hCG was related to oocyte maturation rate (P=0.046). The cut-off point of 12 hours post-injection serum hCG to predict better oocyte maturation rate was 90.15 mIU/mL (sensitivity 68.2%, specificity 83.3%). Oocyte maturation rate may be predicted using body mass index (BMI) and 12 hours post-injection serum hCG. CONCLUSION Higher 12 hours post-injection serum hCG was associated with a higher oocyte maturation rate in IVF subjects.
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Affiliation(s)
- Budi Wiweko
- Reproductive Immunoendocrinology Division, Department of Obstetrics and Gynecology, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia.
- Yasmin IVF Clinic, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
- Human Reproduction, Infertility, and Family Planning Cluster, Indonesia Reproductive Medicine Research and Training Center, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Ervan Surya
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Vita Silvana
- Reproductive Immunoendocrinology Division, Department of Obstetrics and Gynecology, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
- Yasmin IVF Clinic, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
- Human Reproduction, Infertility, and Family Planning Cluster, Indonesia Reproductive Medicine Research and Training Center, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Mila Maidarti
- Reproductive Immunoendocrinology Division, Department of Obstetrics and Gynecology, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
- Yasmin IVF Clinic, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
- Human Reproduction, Infertility, and Family Planning Cluster, Indonesia Reproductive Medicine Research and Training Center, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Achmad Kemal Harzif
- Reproductive Immunoendocrinology Division, Department of Obstetrics and Gynecology, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
- Yasmin IVF Clinic, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
- Human Reproduction, Infertility, and Family Planning Cluster, Indonesia Reproductive Medicine Research and Training Center, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Gita Pratama
- Reproductive Immunoendocrinology Division, Department of Obstetrics and Gynecology, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
- Yasmin IVF Clinic, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
- Human Reproduction, Infertility, and Family Planning Cluster, Indonesia Reproductive Medicine Research and Training Center, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Kanadi Sumapraja
- Reproductive Immunoendocrinology Division, Department of Obstetrics and Gynecology, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
- Yasmin IVF Clinic, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
- Human Reproduction, Infertility, and Family Planning Cluster, Indonesia Reproductive Medicine Research and Training Center, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - R Muharam
- Reproductive Immunoendocrinology Division, Department of Obstetrics and Gynecology, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
- Yasmin IVF Clinic, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
- Human Reproduction, Infertility, and Family Planning Cluster, Indonesia Reproductive Medicine Research and Training Center, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Andon Hestiantoro
- Reproductive Immunoendocrinology Division, Department of Obstetrics and Gynecology, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
- Yasmin IVF Clinic, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
- Human Reproduction, Infertility, and Family Planning Cluster, Indonesia Reproductive Medicine Research and Training Center, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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Stovezky YR, Romanski PA, Bortoletto P, Spandorfer SD. Antimüllerian hormone is not associated with embryo ploidy in patients with and without infertility undergoing in vitro fertilization with preimplantation genetic testing. Fertil Steril 2023; 119:444-453. [PMID: 36423663 DOI: 10.1016/j.fertnstert.2022.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the association between antimüllerian hormone (AMH) and embryo ploidy rates in 2 cohorts of patients undergoing in vitro fertilization (IVF) with trophectoderm biopsy for preimplantation genetic testing for aneuploidy (PGT-A): the general population of women pursuing IVF with PGT-A (Infertile cohort) and women pursuing IVF with preimplantation genetic testing for monogenic disorders (PGT-M) owing to the risk of hereditary monogenic diseases (Non-infertile cohort). DESIGN Retrospective cohort study. SETTING Academic center. PATIENT(S) Patients undergoing their first cycle of IVF with trophectoderm biopsy and PGT-A or PGT-A and PGT-M in our center between March 2012 and June 2020. Patients of advanced maternal age according to the Bologna criteria (age ≥40 years) and patients who underwent fresh embryo transfers were excluded. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Proportion of euploid, mosaic, and aneuploid embryos per cycle. RESULT(S) "Infertile" (n = 926) and "Non-infertile" (n = 214) patients were stratified on the basis of AMH levels, with low-AMH defined as <1.1 ng/mL in accordance with the Bologna criteria. Age-adjusted regression models showed no relationship between AMH classification and proportion of euploid, mosaic, and aneuploid embryos in the Infertile or Non-infertile cohorts. In the Infertile cohort, no association between AMH classification and embryo ploidy rates was identified in a subgroup analysis of patients aged <35 years, 35-37 years, and 38-39 years. These findings persisted in a sensitivity analysis of infertile patients stratified into AMH (ng/mL) quartile categories. CONCLUSION(S) No association was found between AMH and the proportion of euploid, mosaic, or aneuploid embryos in 2 large cohorts of patients undergoing IVF with PGT-A (Infertile patients) or PGT-A and PGT-M (Non-infertile patients), suggesting that a quantitative depletion of ovarian reserve does not predict the ploidy status of the embryo cohort.
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Affiliation(s)
- Yael R Stovezky
- Weill Medical College of Cornell University, New York, New York.
| | - Phillip A Romanski
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, New York
| | - Pietro Bortoletto
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, New York
| | - Steven D Spandorfer
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, New York
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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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9
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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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Svenstrup L, Möller S, Fedder J, Pedersen D, Erb K, Andersen C, Humaidan P. Does the hCG trigger dose used for final oocyte maturation in IVF impact luteal phase progesterone levels? - A randomized controlled trial. Reprod Biomed Online 2022; 45:793-804. [DOI: 10.1016/j.rbmo.2022.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 04/12/2022] [Accepted: 04/29/2022] [Indexed: 11/16/2022]
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Romanski PA, Aluko A, Bortoletto P, Elias R, Rosenwaks Z. Age-specific blastocyst conversion rates in embryo cryopreservation cycles. Reprod Biomed Online 2022; 45:432-439. [DOI: 10.1016/j.rbmo.2022.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 04/06/2022] [Accepted: 04/12/2022] [Indexed: 10/18/2022]
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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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Stovezky YR, Romanski PA, Bortoletto P, Spandorfer SD. Body mass index is not associated with embryo ploidy in patients undergoing in vitro fertilization with preimplantation genetic testing. Fertil Steril 2021; 116:388-395. [PMID: 33827765 DOI: 10.1016/j.fertnstert.2021.02.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 02/16/2021] [Accepted: 02/16/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To assess the association between body mass index (BMI) and embryo aneuploidy and mosaicism in a cohort of patients undergoing in vitro fertilization (IVF) with trophectoderm biopsy for preimplantation genetic testing for aneuploidy (PGT-A) using next-generation sequencing technology. DESIGN Retrospective cohort study. SETTING Academic center. PATIENTS Patients undergoing their first IVF cycle with trophectoderm biopsy and PGT-A at our center between January 1, 2017, and August 31, 2020. Patients classified as underweight on the basis of BMI (BMI <18.5 kg/m2) and patients who underwent fresh embryo transfers were excluded. INTERVENTION None. MAIN OUTCOME MEASURES Number and proportion of aneuploid, mosaic, and euploid embryos. RESULTS The patients were stratified according to the World Health Organization's BMI classification: normal weight (18.5-24.9 kg/m2, n = 1,254), overweight (25-29.9 kg/m2, n = 351), and obese (≥30 kg/m2, n = 145). Age-adjusted regression models showed no relationship between BMI classification and the number or proportion of aneuploid embryos. There were no statistically significant associations between BMI classifications and the number or proportion of mosaic or euploid embryos. A subgroup analysis of patients classified into age groups of <35, 35-40, and >40 years similarly showed no relationships between BMI and embryo ploidy outcomes. CONCLUSION Body mass index was not associated with the number or proportion of aneuploid, mosaic, or euploid embryos in this large cohort of patients undergoing IVF with PGT-A, suggesting that the negative effect of excess weight on reproductive outcomes was independent of the ploidy status of the embryo cohort.
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Affiliation(s)
- Yael R Stovezky
- Weill Medical College of Cornell University, New York, New York
| | - Phillip A Romanski
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, New York.
| | - Pietro Bortoletto
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, New York
| | - Steven D Spandorfer
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, New York
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Romanski PA, Bortoletto P, Magaoay B, Chung A, Rosenwaks Z, Spandorfer SD. Live birth outcomes in infertile patients with class III and class IV obesity following fresh embryo transfer. J Assist Reprod Genet 2021; 38:347-355. [PMID: 33200310 PMCID: PMC7884488 DOI: 10.1007/s10815-020-02011-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 11/09/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Assess the effect of class III (body mass index [BMI, kg/m2] 40-49.9) and class IV obesity (≥ 50) on clinical pregnancy and live birth outcomes after first oocyte retrieval and fresh embryo transfer cycle. DESIGN Cohort study SETTING: Academic center PATIENTS: Patients undergoing their first oocyte retrieval with planned fresh embryo transfer in our clinic between 01/01/2012 and 12/31/2018. Patients were stratified by BMI: 18.5-24.9 (n = 4913), 25-29.9 (n = 1566) 30-34.9 (n = 559), 35-39.9 (n = 218), and ≥ 40 (n = 114). INTERVENTION None MAIN OUTCOME MEASURE: Live birth rate RESULTS: Following embryo transfer, there were no differences in pregnancy rates across all BMI groups (p value, linear trend = 0.86). However among pregnant patients, as BMI increased, a significant trend of a decreased live birth rate was observed (p value, test for linear trend = 0.004). Additionally, as BMI increased, a significant trend of an increased miscarriage rate was observed (p value, linear trend = < 0.001). Compared to the normal-weight cohort, women with a BMI ≥ 40 had a significantly higher rate of cancelled fresh transfers after retrieval (18.4% vs. 8.2%, OR 2.51; 95%CI 1.55-4.08). Among singleton deliveries, a significant trend of an increased c-section rate was identified as the BMI increased (p value, linear trend = <0.001). CONCLUSION Overall, patients with a BMI > 40 have worse IVF treatment outcomes compared to normal-weight patients. After embryo transfer, their pregnancy rate is comparable to normal-weight women; however, their miscarriage rate is higher, leading to a lower live birth rate for pregnant women in this population. Patients with a BMI > 40 have a c-section rate that is 50% higher than normal-weight patients.
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Affiliation(s)
- Phillip A Romanski
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, 1305 York Avenue, New York, NY, 10021, USA
| | - Pietro Bortoletto
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, 1305 York Avenue, New York, NY, 10021, USA
| | - Brady Magaoay
- Weill Medical College of Cornell University, New York, NY, 10021, USA
| | - Alice Chung
- Weill Medical College of Cornell University, New York, NY, 10021, USA
| | - Zev Rosenwaks
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, 1305 York Avenue, New York, NY, 10021, USA
| | - Steven D Spandorfer
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, 1305 York Avenue, New York, NY, 10021, USA.
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Kitasaka H, Tokoro M, Kojima M, Fukunaga N, Asada Y. Gonadotropin levels at the start of ovarian stimulation predict normal fertilization after hCG re-trigger in GnRH antagonist cycles. Reprod Med Biol 2021; 20:96-107. [PMID: 33488289 PMCID: PMC7812458 DOI: 10.1002/rmb2.12359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 09/30/2020] [Accepted: 11/16/2020] [Indexed: 11/21/2022] Open
Abstract
PURPOSE To assess the appropriateness of human chorionic gonadotropin (hCG) re-trigger in poor responders to gonadotropin-releasing hormone agonist (GnRHa) trigger in controlled ovarian stimulation (COS) cycles. METHODS The 2251 cycles in 2251 patients triggered with GnRHa for oocyte stimulation, with or without requiring hCG re-trigger between 2013 and 2018, were retrospectively analyzed to compare gonadotropin levels at the start of COS and the rate of normal fertilization between the re-trigger and non-re-trigger group. Furthermore, patients in the re-trigger group were stratified by the rate of normal fertilization (good: ≥60% or poor: <60%) to compare patient demographics, hormone profiles, and clinical outcome between the subgroups. RESULTS In the re-trigger group, FSH and LH levels at the start of COS were significantly lower in the good fertilization group than in the poor fertilization group (P < .01). Receiver operating characteristic curves identified cutoff values of the FSH and LH levels of 1.30 and 0.35 mIU/mL, respectively, for predicting ≥60% normal fertilization. CONCLUSION Gonadotropin levels at the start of COS are predictors of response to GnRHa trigger and hCG re-trigger necessity, and may serve as indicators to help clinicians appropriately choose hCG re-trigger rather than abandoning the cycles or continuing the first oocyte aspiration attempt.
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Affiliation(s)
| | - Mikiko Tokoro
- Asada Ladies ClinicNagoyaJapan
- Asada Institute for Reproductive MedicineKasugaiJapan
| | | | - Noritaka Fukunaga
- Asada Ladies ClinicNagoyaJapan
- Asada Institute for Reproductive MedicineKasugaiJapan
| | - Yoshimasa Asada
- Asada Ladies ClinicNagoyaJapan
- Asada Institute for Reproductive MedicineKasugaiJapan
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16
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Vishnevsky G, Shoham Z, Or Y. Is there a pre-retrieval serum human chorionic gonadotrophin (hCG) threshold level for prediction of subsequent retrieval outcomes and pregnancy in fresh ICSI cycles? Gynecol Endocrinol 2020; 36:641-645. [PMID: 31847630 DOI: 10.1080/09513590.2019.1699049] [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: 10/25/2022] Open
Abstract
Modern ICSI (intracytoplasmic sperm injection) cycles' outcomes are difficult to predict. Whether human chorionic gonadotrophin (hCG) or luteinizing hormone (LH) serum levels 24 h prior to oocyte retrieval are correlated with retrieval and subsequent cycle results is unclear. An observational historic cohort study of 645 fresh ICSI cycles was conducted. After controlled oocyte stimulation, and 10-12 h after a self-administered trigger, serum levels of hCG (hCG trigger n = 563) and LH (GnRHa trigger n = 82) were measured. Correlations between pre-retrieval hormone levels and cycle results were assessed. No correlation (p > .12) was found between serum pre-retrieval hCG levels or LH levels (in GnRHa-triggered cycles) and total oocytes, M2, M1 + M2 or oocyte maturity rates (OMR) for any of the stimulation protocols. ROC (receiver operator curve) analysis for fertilization rates showed a possible cutoff for LH levels. Pregnancy rates (PR) were higher in rising hCG groups; a cutoff of 117 IU/L was associated with an increase in PR (30.9% to 45.6%) and a moderate sensitivity and specificity (60.6% and 55.0%). However, HCG was not predictive of pregnancy in a logistic regression model. We conclude that preretrieval hCG serum levels are not useful for pre-retrieval estimation of aspiration results but might have a role in prediction of pregnancy.
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Affiliation(s)
- Guy Vishnevsky
- Hebrew University of Jerusalem, Jerusalem, Israel
- Hadassah Medical Center, Jerusalem, Israel
| | - Zeev Shoham
- Kaplan Medical Center, The IVF unit, Rehovot, Israel
- Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yuval Or
- Kaplan Medical Center, Rehovot, Israel
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Castiglione Morelli MA, Iuliano A, Schettini SCA, Petruzzi D, Ferri A, Colucci P, Viggiani L, Ostuni A. Metabolic changes in follicular fluids of patients treated with recombinant versus urinary human chorionic gonadotropin for triggering ovulation in assisted reproductive technologies: a metabolomics pilot study. Arch Gynecol Obstet 2020; 302:741-751. [PMID: 32462220 DOI: 10.1007/s00404-020-05609-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 05/19/2020] [Indexed: 01/16/2023]
Abstract
INTRODUCTION The main goal of this retrospective cohort study is the assessment of the effects of administration of recombinant-hCG (r-hCG) versus urinary-hCG (u-hCG) on follicular fluid (FF) composition of women who underwent in vitro fertilization (IVF) treatments. MATERIALS AND METHODS We selected 70 patients with infertility attributable to tubal diseases, unexplained infertility, and male factor. Metabolomics analysis of their FFs was performed by 1H nuclear magnetic resonance (1H NMR) spectroscopy in combination with multivariate analysis to interpret the spectral data. Univariate statistical analysis was applied to investigate the possible correlations between clinical parameters and between clinical parameters and metabolites identified by NMR. RESULTS According to the type of hCG used, significant differences were detected in FFs of women with male factor and unexplained infertility, both in qualitative and quantitative terms, for some metabolites as cholesterol, citrate, creatine, β-hydroxybutyrate, glycerol, lipids, amino acids (Glu, Gln, His, Val, Lys) and glucose. No significant difference was observed in women with tubal diseases. Besides, the number of MII oocytes in the u-hCG-treated groups correlates positively with glutamate in tubal disease and with glycerol in unexplained infertility. In the r-hCG-treated groups, the number of MII oocytes correlates positively with lipid in tubal disease, positively with citrate and negatively with glucose in male infertility. CONCLUSIONS Metabolite composition of FF changes according to different type of hCG treatment and this can be related to oocyte development and subsequent outcome. According to the data of this study, different types of hCG should be used in relation to the diagnosis of infertility to obtain better results in inducing oocyte maturation in women undergoing IVF.
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Affiliation(s)
| | - Assunta Iuliano
- Center for Reproductive Medicine of "San Carlo" Hospital, via Potito Petrone, 85100, Potenza, Italy
| | | | - Donatina Petruzzi
- Center for Reproductive Medicine of "San Carlo" Hospital, via Potito Petrone, 85100, Potenza, Italy
| | - Angela Ferri
- Center for Reproductive Medicine of "San Carlo" Hospital, via Potito Petrone, 85100, Potenza, Italy
| | - Paola Colucci
- Center for Reproductive Medicine of "San Carlo" Hospital, via Potito Petrone, 85100, Potenza, Italy
| | - Licia Viggiani
- Department of Sciences, University of Basilicata, viale Ateneo Lucano 10, 85100, Potenza, Italy
| | - Angela Ostuni
- Department of Sciences, University of Basilicata, viale Ateneo Lucano 10, 85100, Potenza, Italy.
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Mizrachi Y, Horowitz E, Farhi J, Raziel A, Weissman A. Ovarian stimulation for freeze-all IVF cycles: a systematic review. Hum Reprod Update 2019; 26:118-135. [DOI: 10.1093/humupd/dmz037] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 09/07/2019] [Accepted: 09/23/2019] [Indexed: 12/30/2022] Open
Abstract
Abstract
BACKGROUND
Freeze-all IVF cycles are becoming increasingly prevalent for a variety of clinical indications. However, the actual treatment objectives and preferred treatment regimens for freeze-all cycles have not been clearly established.
OBJECTIVE AND RATIONALE
We aimed to conduct a systematic review of all aspects of ovarian stimulation for freeze-all cycles.
SEARCH METHODS
A comprehensive search in Medline, Embase and The Cochrane Library was performed. The search strategy included keywords related to freeze-all, cycle segmentation, cumulative live birth rate, preimplantation genetic diagnosis, preimplantation genetic testing for aneuploidy, fertility preservation, oocyte donation and frozen-thawed embryo transfer. We included relevant studies published in English from 2000 to 2018.
OUTCOMES
Our search generated 3292 records. Overall, 69 articles were included in the final review. Good-quality evidence indicates that in freeze-all cycles the cumulative live birth rate increases as the number of oocytes retrieved increases. Although the risk of severe ovarian hyperstimulation syndrome (OHSS) is virtually eliminated in freeze-all cycles, there are certain risks associated with retrieval of large oocyte cohorts. Therefore, ovarian stimulation should be planned to yield between 15 and 20 oocytes. The early follicular phase is currently the preferred starting point for ovarian stimulation, although luteal phase stimulation can be used if necessary. The improved safety associated with the GnRH antagonist regimen makes it the regimen of choice for ovarian stimulation in freeze-all cycles. Ovulation triggering with a GnRH agonist almost completely eliminates the risk of OHSS without affecting oocyte and embryo quality and is therefore the trigger of choice. The addition of low-dose hCG in a dual trigger has been suggested to improve oocyte and embryo quality, but further research in freeze-all cycles is required. Moderate-quality evidence indicates that in freeze-all cycles, a moderate delay of 2–3 days in ovulation triggering may result in the retrieval of an increased number of mature oocytes without impairing the pregnancy rate. There are no high-quality studies evaluating the effects of sustained supraphysiological estradiol (E2) levels on the safety and efficacy of freeze-all cycles. However, no significant adverse effects have been described. There is conflicting evidence regarding the effect of late follicular progesterone elevation in freeze-all cycles.
WIDER IMPLICATIONS
Ovarian stimulation for freeze-all cycles is different in many aspects from conventional stimulation for fresh IVF cycles. Optimisation of ovarian stimulation for freeze-all cycles should result in enhanced treatment safety along with improved cumulative live birth rates and should become the focus of future studies.
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Affiliation(s)
- Yossi Mizrachi
- IVF Unit, Department of Obstetrics & Gynecology, the Edith Wolfson Medical Center, Holon, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Eran Horowitz
- IVF Unit, Department of Obstetrics & Gynecology, the Edith Wolfson Medical Center, Holon, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Jacob Farhi
- IVF Unit, Department of Obstetrics & Gynecology, the Edith Wolfson Medical Center, Holon, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Arieh Raziel
- IVF Unit, Department of Obstetrics & Gynecology, the Edith Wolfson Medical Center, Holon, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ariel Weissman
- IVF Unit, Department of Obstetrics & Gynecology, the Edith Wolfson Medical Center, Holon, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Triggering method in assisted reproduction alters the cumulus cell transcriptome. Reprod Biomed Online 2019; 39:211-224. [DOI: 10.1016/j.rbmo.2019.03.213] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 03/18/2019] [Accepted: 03/21/2019] [Indexed: 11/21/2022]
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Namavar Jahromi B, Zolghadri J, Rahmani E, Alipour S, Anvar Z, Zarei A, Keramati P. Effect of low-dose aspirin on the development of ovarian hyperstimulation syndrome and outcomes of assisted reproductive techniques in the women with PCOS, a randomized double-blinded clinical trial. Taiwan J Obstet Gynecol 2019; 58:255-260. [PMID: 30910149 DOI: 10.1016/j.tjog.2019.01.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2018] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE Ovarian hyperstimulation syndrome (OHSS) is a major complication of assisted reproductive technologies (ART). Polycystic ovary syndrome (PCOS) is a risk factor for OHSS. The aim of this randomized clinical trial (RCT) was to study the effect of low-dose aspirin (LDA) on the development of OHSS and ART outcomes in PCOS during ART. MATERIALS AND METHODS This double-blinded placebo controlled RCT was performed on 232 PCOS infertile women in their first ART cycles during 2010-2016. LDA and placebo capsules were prepared, packed and specified by code numbers in similar shapes. One package was given to every woman and asked to take one capsule/day since the 21st day of her cycle prior to the gonadotropin stimulation. Gonadotropin releasing hormone agonist long protocol and triggering by human chorionic gonadotropin were used. Development of moderate to severe OHSS and their ART outcomes were documented then the codes were broken and data analyzed. Chi-square and Mann-Whitney U tests were used for the statistical analyses. RESULTS Eighteen cases that did not follow the study design were excluded. 214 cycles remained for the final analyses with 109 cases in LDA and 105 in the placebo group. Rate of the moderate to severe OHSS in LDA group was 34.9% compared to 30.5% in placebo group (P = 0.494). Fertilization rate was 71.8% vs 65.1% (P = <0.001) and the mean number of grade III embryos were 3.28 ± 3.53 vs 1.46 ± 1.42 (P = 0.014) in LDA and placebo groups, respectively. The mean number of the oocytes in different grades, total and frozen embryos also implantation and clinical pregnancy rates were not different between the groups. CONCLUSION Moderate to Severe OHSS was not decreased but fertilization rate and the mean number of poor quality embryos were increased in LDA arm. REGISTRATION NUMBER IRCT 201105216541N1.
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Affiliation(s)
- Bahia Namavar Jahromi
- Infertility Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Department of Obstetrics and Gynecology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Jaleh Zolghadri
- Infertility Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Department of Obstetrics and Gynecology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Elham Rahmani
- OB and GYN Ward, Bushehr University of Medical Sciences, Bushehr, Iran.
| | - Shohreh Alipour
- Department of Pharmaceutics, Department of Pharmaceutical Quality Control, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Zahra Anvar
- Infertility Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Department of Obstetrics and Gynecology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Afsun Zarei
- Infertility Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Department of Obstetrics and Gynecology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Pegah Keramati
- Infertility Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Department of Obstetrics and Gynecology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
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Gunnala V, Fields J, Irani M, D'Angelo D, Xu K, Schattman G, Rosenwaks Z. BRCA carriers have similar reproductive potential at baseline to noncarriers: comparisons in cancer and cancer-free cohorts undergoing fertility preservation. Fertil Steril 2018; 111:363-371. [PMID: 30527950 DOI: 10.1016/j.fertnstert.2018.10.014] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 08/15/2018] [Accepted: 10/15/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To investigate whether BRCA carriers with and without malignancy have decreased ovarian reserve at baseline compared with BRCA noncarriers. DESIGN Retrospective cohort study. SETTING Academic medical center. PATIENT(S) Seven-hundred and ninety-five oocyte cryopreservation patients, comprising BRCA carriers with and without malignancy (n = 57) and BRCA noncarriers (n = 738). INTERVENTION(S) Fertility preservation with oocyte cryopreservation. MAIN OUTCOME MEASURE(S) Antral follicle count (AFC), antimüllerian hormone (AMH) concentration, day-3 follicle-stimulating hormone (FSH) level, number of harvested oocytes, and number of mature/cryopreserved oocytes. RESULT(S) In the cancer cohort we compared BRCA-positive breast cancer (n = 38) with BRCA-negative breast cancer (n = 53) and with non-breast-cancer malignancies (n = 85). In the cancer-free cohort we compared BRCA carriers (n = 19) with women undergoing elective egg freezing (n = 600). We also compared the BRCA1 (n = 31) versus the BRCA2 carriers (n = 18). The patients' mean ages were 32.4 ± 3.6 years and 35.5 ± 4.3 years in the BRCA carrier and noncarrier cohorts, respectively. BRCA status was associated with a higher day-3 FSH level in the cancer cohort, but we found no changes in the other outcomes compared with the BRCA-negative cancer groups. BRCA carriers without cancer exhibited a higher AFC and number of mature oocytes compared with the patients undergoing planned egg freezing. Overall (cancer and cancer-free cohorts), the BRCA carriers had an increased AFC (15.5 ± 4.6 vs. 12.6 ± 5.7) and number of mature/cryopreserved oocytes (14.0 ± 7.9 vs. 10.4 ± 6.9) compared with the BRCA noncarriers but had no differences in other outcomes. CONCLUSION(S) BRCA carriers with and without malignancy exhibit comparable ovarian reserve and responses to ovarian stimulation compared with women with BRCA-negative cancers and cancer-free controls.
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Affiliation(s)
- Vinay Gunnala
- Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medicine, New York, New York.
| | - Jessica Fields
- Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, New York
| | - Mohamad Irani
- Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medicine, New York, New York
| | - Debra D'Angelo
- Division of Biostatistics and Epidemiology, Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, New York
| | - Kangpu Xu
- Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medicine, New York, New York
| | - Glenn Schattman
- Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medicine, New York, New York
| | - Zev Rosenwaks
- Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medicine, New York, New York
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22
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Abbara A, Clarke SA, Dhillo WS. Novel Concepts for Inducing Final Oocyte Maturation in In Vitro Fertilization Treatment. Endocr Rev 2018; 39:593-628. [PMID: 29982525 PMCID: PMC6173475 DOI: 10.1210/er.2017-00236] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 06/27/2018] [Indexed: 01/20/2023]
Abstract
Infertility affects one in six of the population and increasingly couples require treatment with assisted reproductive techniques. In vitro fertilization (IVF) treatment is most commonly conducted using exogenous FSH to induce follicular growth and human chorionic gonadotropin (hCG) to induce final oocyte maturation. However, hCG may cause the potentially life-threatening iatrogenic complication "ovarian hyperstimulation syndrome" (OHSS), which can cause considerable morbidity and, rarely, even mortality in otherwise healthy women. The use of GnRH agonists (GnRHas) has been pioneered during the last two decades to provide a safer option to induce final oocyte maturation. More recently, the neuropeptide kisspeptin, a hypothalamic regulator of GnRH release, has been investigated as a novel inductor of oocyte maturation. The hormonal stimulus used to induce oocyte maturation has a major impact on the success (retrieval of oocytes and chance of implantation) and safety (risk of OHSS) of IVF treatment. This review aims to appraise experimental and clinical data of hormonal approaches used to induce final oocyte maturation by hCG, GnRHa, both GnRHa and hCG administered in combination, recombinant LH, or kisspeptin. We also examine evidence for the timing of administration of the inductor of final oocyte maturation in relationship to parameters of follicular growth and the subsequent interval to oocyte retrieval. In summary, we review data on the efficacy and safety of the major hormonal approaches used to induce final oocyte maturation in clinical practice, as well as some novel approaches that may offer fresh alternatives in future.
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Affiliation(s)
- Ali Abbara
- Department of Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Sophie A Clarke
- Department of Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Waljit S Dhillo
- Department of Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
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23
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Pan SP, Chao KH, Huang CC, Wu MY, Chen MJ, Chang CH, Yang JH, Yang YS, Chen SU. Early stop of progesterone supplementation after confirmation of pregnancy in IVF/ICSI fresh embryo transfer cycles of poor responders does not affect pregnancy outcome. PLoS One 2018; 13:e0201824. [PMID: 30092070 PMCID: PMC6084928 DOI: 10.1371/journal.pone.0201824] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 07/23/2018] [Indexed: 12/21/2022] Open
Abstract
Previous studies indicated that progesterone can be withdrawn at the time of the first positive β-hCG test without compromising the clinical pregnancy outcome in normal ovarian responder. However, the effect of early stop of progesterone supplementation for patients with poor ovarian response (POR) has not been investigated. This study retrospectively collected data from patients with POR in 156 IVF/ICSI fresh embryo transfer (ET) cycles in single tertiary center from January 2010 to June 2016. All the patients met ESHRE consensus, the Bologna criteria, of POR and had hCG injection for luteal phase support (LPS) on day 2, 5 and 8 after ovum pick-up. The pregnant patients were divided into two groups: early stop group represented those who stopped LPS from day of positive pregnancy test; control group represented those who kept progesterone supplementation till gestational age of 9 weeks. There were no significant differences in age, BMI, parity, hormone data, number of follicles>10(mm), endometrial thickness and number of embryos transferred between the two groups. After adjustment for possible confounders with multivariate logistic regression analysis, the clinical pregnancy rates (55.0% vs. 57.1%, P = 0.35), ongoing pregnancy rates (47.0% vs. 46.4%, P = 0.66), miscarriage rates (34.0% vs. 26.7%, P = 0.66) and live-birth rates (44.0% vs. 46.4%, P = 0.41) were not statistically different between early stop group and the control group. Our study indicates that early stop of progesterone supplementation on the day of positive pregnancy test for patients of POR using hCG as LPS in fresh ET cycles does not affect pregnancy outcome.
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Affiliation(s)
- Song-Po Pan
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
| | - Kuang-Han Chao
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chu-Chun Huang
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Yih Wu
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
| | - Mei-Jou Chen
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
- Livia Shanyu Wan Scholar, College of Medicine, National Taiwan University
| | - Chin-Hao Chang
- Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
| | - Jehn-Hsiahn Yang
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Shih Yang
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
| | - Shee-Uan Chen
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
- * E-mail:
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24
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Stanekova V, Woodman RJ, Tremellen K. The rate of euploid miscarriage is increased in the setting of adenomyosis. Hum Reprod Open 2018; 2018:hoy011. [PMID: 30895252 PMCID: PMC6276689 DOI: 10.1093/hropen/hoy011] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 05/22/2018] [Accepted: 06/14/2018] [Indexed: 12/22/2022] Open
Abstract
STUDY QUESTION Does the rate of miscarriage increase in the setting of adenomyosis independent of other known risk factors for miscarriage such as maternal age, BMI, embryo genetic status? SUMMARY ANSWER Adenomyosis and high BMI both significantly increase miscarriage risk independent of each other, maternal age and embryo health. This study is the first to suggest that ultra-long down regulation GnRH agonist treatment may reduce the rate of early pregnancy loss in adenomyosis patients. WHAT IS KNOWN ALREADY The presence of adenomyosis is known to be associated with lower rates of successful implantation and increased risk of early pregnancy loss. However, it is presently unclear whether this reproductive impairment is directly mediated by adenomyosis itself, or indirectly caused by adenomyosis association with known risk factors for miscarriage such as obesity and advancing maternal age/foetal aneuploidy. STUDY DESIGN SIZE DURATION A retrospective cohort study was undertaken in a private infertility (IVF) clinic examining the outcome for women (n = 345) undergoing the transfer of a genetically screened frozen-thawed embryo between 2012 and 2015. PARTICIPANTS/MATERIALS SETTING AND METHOD A total of 171 women who successfully conceived (positive serum βhCG) following the transfer of a single euploid good morphology frozen-thawed embryo were included in analysis after meeting the inclusion criteria. Only the first conception cycle for each patient was included in the study. Patients with known pre-existing medical risk factors for miscarriage (e.g. thrombophilia, poorly controlled diabetes, coeliac disease, SLE, uterine septum, chromosomal abnormalities) and those women undergoing treatment using donated oocytes and surrogacy were excluded. Patients were then classified as having adenomyosis or not based on a high-quality pelvic ultrasound or MRI. The direct and indirect effects of adenomyosis and BMI on overall miscarriage rate by 12 weeks gestation was then assessed using multivariate logistic regression and mediation analysis. Furthermore, the data were also analysed to elucidate the influence of GnRH ultra-long down-regulation therapy on miscarriage rates. MAIN RESULTS AND ROLE OF CHANCE Overall, the adjusted rate of miscarriage was higher in those patients with adenomyosis compared to those without (44.1 vs 15.3%, P < 0.0001), with most of these miscarriages occurring at the early biochemical stage. The rate of miscarriage was especially high in adenomyosis patients not receiving GnRH agonist pre-treatment (82.4%), compared to those patients who did receive GnRH pre-treatment (35.7%, P = 0.0089). LIMITATIONS REASONS FOR CAUTION The study is mainly limited by its small sample size and retrospective design which carries inherent potential for bias (i.e. misclassification and errors due to inadequate clinical notes). The small sample size precluded analysis to distinguish how the extent of adenomyosis disease may modify miscarriage risk (i.e. focal or diffuse disease). Furthermore, the relatively low number of adenomyosis patients not receiving GnRH agonist treatment, plus the non-randomized nature of the decision not to offer such treatment, precludes definitive conclusions on the benefit of GnRH agonist therapy to reduce miscarriage risk. WIDER IMPLICATIONS OF THE FINDINGS Considering the significant emotional and financial impact of miscarriage, we suggest screening of all women undergoing IVF treatment for the presence of adenomyosis, with consideration given to ultra-long down regulation GnRH agonist treatment in any woman identified as having adenomyosis. Furthermore, given the persistent and often progressive nature of the disease, adenomyosis should also be considered as a potential uterine cause of recurrent miscarriage. Finally, we hope our study highlights the need for high-quality prospective RCT to be undertaken to provide superior evidence for the potential benefit of GnRH agonist pre-treatment. STUDY FUNDING/COMPETING INTERESTS K.T. is a practicing IVF gynaecologist and holds a minority stake in the publicly listed company Monash IVF. The other authors declare that they have no conflict of interest. This study was financially supported by Flinders University Medical School.
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Affiliation(s)
- V Stanekova
- College of Medicine and Public Health, Flinders University, Sturt Road, Bedford Park, South Australia, Australia
| | - R J Woodman
- Flinders Centre for Epidemiology and Biostatistics, Sturt Road, Bedford Park, South Australia, Australia
| | - K Tremellen
- College of Medicine and Public Health, Flinders University, Sturt Road, Bedford Park, South Australia, Australia.,Repromed, 180 Fullarton Road, Dulwich, South Australia, Australia
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