Effect of Endometrium Thickness on Clinical Outcomes in Luteal Phase Short-Acting GnRH-a Long Protocol and GnRH-Ant Protocol

The association between female age and pregnancy outcomes in patients receiving first elective single embryo transfer cycle: a retrospective cohort study

This study aimed to explore the relationship between female age and pregnancy outcomes in patients undergoing their first elective single embryo transfer (eSET) of in vitro fertilization (IVF) cycles. The retrospective cohort study encompassed 7089 IVF/intracytoplasmic sperm injection (ICSI) patients of the Reproductive Medicine Center, Henan Provincial Peoples' Hospital of China, from September 1, 2016, to May 31, 2022. Patients all received the first eSET in their IVF/ICSI cycles. A generalized additive model (GAM) was employed to examine the the dose-response correlation between age and pregnancy outcomes, namely the clinical pregnancy rate (CPR) and ongoing pregnancy rate (OPR). Logistic regression model was employed to ascertain the correlation between the CPR/OPR and age. The study cohort has an average age of 30.74; 3843 patients got clinical pregnancy rate of 61.40% and ongoing pregnancy rate of 54.21%. The multiple pregnancy rate of is 1.24%. For patients aged 34 and above, the CPR decreased by 10% for every 1-year increase in age (adjusted OR 0.90, 95% CI 0.84-0.96, p < 0.0001). Similarly, the OPR decreased by 16% for every 1-year increase in age (adjusted OR 0.84, 95% CI 0.81-0.88, p < 0.0001). Patients aged 35-37 years had an acceptable OPR of 52.4% after eSET, with a low multiple pregnancy rate (1.1%). Pregnancy outcomes were significantly better in blastocyst cycles compared to cleavage embryo cycles, and this trend was more pronounced in older patients. There was a non-linear relationship between female age and pregnancy outcomes in patients undergoing their first eSET cycles. The clinical pregnancy rate and ongoing pregnancy rate decreased significantly with age, especially in women older than 34 years. For patients under 37 years old, single embryo transfer should be prioritized. For patients over 38 years old with available blastocysts, eSET is also recommended.

Economic evaluation of GnRH-agonist long protocol and GnRH-antagonist protocol in IVT/ICSI among the Chinese population: using pharmacoeconomic models

OBJECTIVE

This paper uses health economics methods to discuss the cost-effectiveness value of long protocol and antagonist protocol for in vitro fertilisation and embryo transfer (ET) in the Chinese population.

DESIGN

Health economic evaluation study.

SETTING

The data needed to construct the model for this study were derived from published studies and other secondary sources in China.

PARTICIPANTS

No patients participated in the study.

MEASURES

The main outcomes were live birth rate (LBR) and cost. From the societal perspective, we considered the direct and indirect costs over the course of the treatment cycles. A cost-effectiveness was measured using the incremental cost-effectiveness ratio and the probability that a protocol has higher net monetary benefit. Sensitivity analysis was carried out to verify the reliability of the simulation results.

RESULTS

For the Chinese population, the long protocol resulted in a higher LBR than the antagonist protocol (29.33% vs 20.39%), but at the same time, it was more expensive (￥29 146.26 (US$4333.17) vs ￥23 343.70 (US$3470.51)), in the case of considering only one fresh ET cycle. It was the same when considering subsequent frozen ET (FET) cycles (51.78% vs 42.81%; ￥30 703.02 (US$4564.62) vs ￥24 740.95 (US$3678.24)). The results of most subgroups were consistent with the results of the basic analysis. However, for certain populations, the long protocol was the inferior protocol (less effective and more expensive).

CONCLUSION

For the Chinese population, when the monetary value per live birth was greater than ￥65 420 (US$9726) and ￥66 400 (US$9872), respectively, considering only one fresh cycle and considering subsequent frozen cycles, the long protocol is the preferred protocol. This threshold also varies for women of different ages and ovarian response capacities. For women in POSEIDON (Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number) group 2, group 3 and group 4, antagonist protocol is recommended as the preferred protocol. The results of this study need to be verified by further large-scale randomised controlled trials.

The association between triglyceride glucose-body Mass Index and in vitro fertilization outcomes in women with polycystic ovary syndrome: a cohort study

BACKGROUND

Polycystic Ovary Syndrome (PCOS) is a common reproductive disorder that frequently affects fertility. The TyG-BMI (Triglyceride glucose-body mass) index is a newly explored parameter that may be linked to reproductive results in individuals with PCOS. Nevertheless, its connection with outcomes in In Vitro Fertilization (IVF) procedures remains uncertain.

METHODS

This study included a total of 966 females who underwent IVF treatments for PCOS. At the baseline, the participants were categorized into four groups according to the quartiles of TyG-BMI measured prior to oocyte retrieval. Subsequently, the study compared the differences in clinical and laboratory outcomes among these four groups.

RESULTS

Patients in higher TyG-BMI quartiles exhibited a decreased number of retrieved oocytes, 2PN embryos, and available/high-quality embryos (P < 0.05 for Q1-Q4). Additionally, the multivariable regression analysis revealed that individuals in the top quartile of TyG-BMI had a lower count of accessible embryos (β = -0.224, P = 0.257) and a decreased number of high-quality embryos (β = -0.352, P = 0.028) in comparison to those in the lowest quartile. Nevertheless, there were no notable variances detected in the rates of pregnancy or live births among these quartiles. Furthermore, a linear correlation was noted between the TyG-BMI index and the quantity of accessible embryos (P-non-linear = 0.6, P-overall < 0.001), along with high-quality embryos (P-nonlinear = 0.026, P-overall = 0.006). In contrast, there was no notable linear correlation found between the TyG-BMI index and the available embryo rate (P-nonlinear = 0.60, P-overall = 0.8).

CONCLUSIONS

The results of this research emphasize the notable correlation between TyG-BMI and IVF results in females diagnosed with PCOS. The interplay of insulin resistance and disorders of lipid metabolism may indeed play a pivotal role in influencing the assisted reproductive outcomes of patients with PCOS. Considering these findings, TyG-BMI proves to be a valuable indicator for exploring this potential association.

The effects of flexible short protocol with gonadotropin-releasing hormone antagonist on preventing premature ovulation in poor responders

PURPOSE

The proportion of patients with poor ovarian response (POR) is increasing, but effective treatment remains a challenge. To control the hidden peaks of luteinizing hormone (LH) and premature ovulation for poor responders, this study investigated the efficacy of flexible short protocol (FSP) with gonadotropin-releasing hormone antagonist (GnRH-ant) on trigger day.

METHODS

The 662 cycles of POR patients were retrospectively analyzed. The cohort was divided into control and intervention groups. The intervention group (group A) with 169 cycles received a GnRH-ant given on trigger day. The control (group B) with 493 cycles received only FSP. The clinical outcomes of the two groups were compared.

RESULTS

Compared with group B, with gonadotropin-releasing hormone antagonist (GnRH-ant) on trigger day in group A the incidences of spontaneous premature ovulation decreased significantly (2.37% vs. 8.72%, P < 0.05). The number of fresh embryo-transfer cycles was 45 in group A and 117 in group B. There were no significant differences in clinical outcomes, including implantation rate, clinical pregnancy rate, live birth rate and the cumulative live birth rate (12.0% vs. 9.34%; 22.22% vs. 21.93%; 17.78% vs. 14.91%; 20.51% vs. 20%, respectively; P > 0.05) between the two group.

CONCLUSION

FSP with GnRH-ant addition on trigger day had no effect on clinical outcomes, but could effectively inhibit the hidden peaks of luteinizing hormone (LH) and spontaneous premature ovulation in POR. Therefore, it is an advantageous option for POR women.

The association between systemic immune-inflammation index and in vitro fertilization outcomes in women with polycystic ovary syndrome: a cohort study

BACKGROUND

As a novel prognostic and inflammatory marker, the systemic immune-inflammation index (SII) has come to the foreground in recent years. SII may be used as an indicator reflecting the progressive inflammatory process in patients with polycystic ovary syndrome (PCOS). This study aimed to evaluate the correlation between SII and assisted reproductive outcomes in PCOS patients.

RESULTS

A total of 966 women undergoing in vitro fertilization (IVF) procedure with PCOS were included in the study. The SII was calculated as platelet count (/L) × neutrophil count (/L)/lymphocyte count (/L). Participants were divided into four groups according to SII quartiles calculated at baseline, and the differences of clinical and laboratory outcomes between these four groups were compared. Moreover, a univariate linear regression model was used to evaluate the associations between SII and the outcomes. Patients in the highest SII quartile (Q4) had lower antral follicle count (AFC), estradiol (E2), and progesterone (P) levels on the day of human chorionic gonadotropin (HCG) start compared with the lower three SII quartiles (Q1-Q3). Moreover, our analysis demonstrated that women in the lower SII quartiles had a higher rate of available embryos and blastocyst formation compared with those in the highest SII quartile. Logarithm of SII correlated negatively with available embryo rate, but not with number of available embryos. Additionally, the results of our multivariate logistic regression analyses indicated that the highest SII quartile was negatively associated with biochemical pregnancy rate (BPR), clinical pregnancy rate (CPR), live birth rate (LBR), and implantation rate (IR). A non-linear relationship between the SII and number of available embryos, with a negative relationship seen to the right of the inflection point was also found.

CONCLUSIONS

The interplay among thrombocytosis, inflammation, and immunity could influence assisted reproductive outcomes in PCOS patients. In this regard, SII may serve as a valuable marker for exploring potential correlations.

Comparison of pregnancy outcome after fresh embryo transfer between GnRH antagonist and GnRH agonist regimens in patients with thin endometrium

Objective

To compare the pregnancy outcome after fresh embryo transfer between GnRH antagonist and GnRH agonist regimens in patients with thin endometrium.

Methods

This retrospective study included all fresh embryo transfers following GnRH agonist or GnRH antagonist protocols in patients with thin endometrium from 2016 to 2021. The thin endometrium was defined as an endometrial thickness of 7.5 mm or less on the triggering day. Multivariant regression analysis was applied to assess the association of GnRH agonist or GnRH antagonist regimen with live birth following fresh embryo transfer in patients with thin endometrium.

Results

A total of 69 and 192 cases were, respectively, included in the GnRH antagonist or GnRH agonist group. The stimulation duration was significantly longer by the GnRH agonist protocol than the GnRH antagonist protocol (11.2 ± 2.1 vs. 9.1 ± 1.9 days, P = 0.002). The rates of clinical pregnancy or live birth were significantly lower in the GnRH antagonist group compared to the GnRH agonist group (26.1 vs. 47.9%, P = 0.027; 17.4 vs. 40.1%, P = 0.01, respectively). Multivariable regression analysis demonstrated that GnRH agonist regimen was related to higher live birth rate compared with GnRH agonist protocol [adjusted OR: 2.6, 95% confidence intervals (CI): 1.3-5.3]. No significant difference in miscarriage rate and the neonatal outcome was present between the two protocols.

Conclusion

Our findings suggest that GnRH agonist protocol results in a higher rate of live birth after fresh embryo transfer than GnRH antagonist protocol in patients with thin endometrium.

Hormone supply to the pituitary gland: A comprehensive investigation of female‑related tumors (Review)

The hypothalamus acts on the pituitary gland after signal integration, thus regulating various physiological functions of the body. The pituitary gland includes the adenohypophysis and neurohypophysis, which differ in structure and function. The hypothalamus-hypophysis axis controls the secretion of adenohypophyseal hormones through the pituitary portal vein system. Thyroid-stimulating hormone, adrenocorticotropic hormone, gonadotropin, growth hormone (GH), and prolactin (PRL) are secreted by the adenohypophysis and regulate the functions of the body in physiological and pathological conditions. The aim of this review was to summarize the functions of female-associated hormones (GH, PRL, luteinizing hormone, and follicle-stimulating hormone) in tumors. Their pathophysiology was described and the mechanisms underlying female hormone-related diseases were investigated.

Characterization of Epigenetic and Molecular Factors in Endometrium of Females with Infertility

Infertility is one of the most rapidly increasing global health concerns of the 21st century. Embryo quality and endometrial thickness and receptivity are the main factors for successful embryo implantation and pregnancy development. Nevertheless, until now, there has been a lack of understanding about the regulation of human endometrium function and its structure. This raises the demand for more research of the human endometrium in these fields. In our study, we analyzed the genetic and epigenetic changes of endometrial tissue’s samples isolated from females admitted for treatment due to male infertility and females diagnosed with reproductive pathologies, who are preparing for assisted reproductive technologies procedures. Using real-time polymerase chain reaction method, we demonstrated that endometrium of females with reproductive pathology has significantly upregulated decidualization related genes HAND2, MUC1, CSF2, increased expression of angiogenesis related gene PDGFA, and increases of overall immune response and inflammation-related genes expression with significant changes of RELA and CXCL10 genes expression. Females with reproductive pathology have altered endometrium epigenetic regulation since expression of miRNAs—specifically, miRNA-34a, miRNA-223, and miRNA-125b—is lower in endometrium of females with reproductive pathology. Our findings suggest that the potential changes in genetic and epigenetic profile of endometrium from females with reproductive pathology could enrich the knowledge in the field of core biological knowledge and treatment of reproductive impairments.

Randomized controlled trial of astaxanthin impacts on antioxidant status and assisted reproductive technology outcomes in women with polycystic ovarian syndrome

PURPOSE

Polycystic ovary syndrome (PCOS), the most common endocrinopathy in women, is typically accompanied by a defective oxidative defense system. Here, we investigated the effect of astaxanthin (AST) as a powerful antioxidant on the oxidative stress (OS) response and assisted reproductive technology (ART) outcomes in PCOS patients.

METHODS

In this double-blind, randomized, placebo-controlled trial, PCOS patients were randomly assigned into two groups. The intervention group received 8 mg AST, and the control group received the placebo daily for 40 days. The primary outcomes were the serum and follicular fluid (FF) levels of the OS biomarkers and the expression levels of the specific genes and proteins in the oxidative stress response pathway. The secondary outcomes were considered ART outcomes.

RESULTS

According to our findings, a 40-day course of AST supplementation led to significantly higher levels of serum CAT and TAC in the AST group compared to the placebo group. However, there were no significant intergroup differences in the serum MDA and SOD levels, as well as the FF levels of OS markers. The expression of Nrf2, HO-1, and NQ-1 was significantly increased in the granulosa cells (GCs) of the AST group. Moreover, the MII oocyte and high-quality embryo rate were significantly increased in the AST group compared to the placebo group. We found no significant intergroup difference in the chemical and clinical pregnancy rates.

CONCLUSION

AST treatment has been shown to increase both serum TAC levels and activation of the Nrf2 axis in PCOS patients' GCs.

TRIAL REGISTRATION

ClincialTrials.gov Identifier: NCT03991286.

GnRH Antagonist Protocol Versus GnRH Agonist Long Protocol: A Retrospective Cohort Study on Clinical Outcomes and Maternal-Neonatal Safety

OBJECTIVE

To evaluate the clinical outcomes and maternal-neonatal safety of gonadotropin releasing hormone antagonist (GnRH-ant) and gonadotropin releasing hormone agonist (GnRH-a) protocols.

METHODS

A total of 2505 women undergoing their first in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) were retrospectively analyzed. Patients were divided into GnRH-ant group (n = 1514) and GnRH-a group (n = 991) according their stimulation protocol. Propensity Score Matching (PSM) was used for balancing the baseline of two groups. The pregnancy outcomes were analyzed in fresh transfer cycles, and the obstetric and perinatal outcomes were calculated in singleton live births of fresh cycles. The primary outcome was the live birth rate. The secondary outcome measures were maternal complications, preterm birth rate, low birthweight rate, multiple pregnancy rate, and moderate-severe OHSS rate.

RESULTS

After 1:1 PSM, baseline characteristics of the GnRH-ant group and GnRH-a group were matched and assigned 991 cycles in each group. Before PSM, there were 700 fresh cycles including 237 singleton live births in the GnRH-ant group and 588 fresh cycles including 187 singleton live births in the GnRH-a group. After PSM, there were 471 fresh cycles including 166 singleton live births in the GnRH-ant group and 588 fresh cycles including 187 singleton live births in the GnRH-a group. No significant differences were observed in the live birth rate (44.6% vs 48.8%), maternal complications, preterm birth rate (9.0% vs 6.4%), and low birthweight rate (17.5% vs 24.1%) between two groups after PSM (P > 0.05). The moderate-severe OHSS rate (2.9% vs 6.0%, P = 0.002) and multiple pregnancy rate (24.5% vs 33.1%, P = 0.025) was significantly lower in the GnRH-ant group than that in the GnRH-a group after PSM.

CONCLUSION

GnRH-ant protocol was comparable with GnRH-a protocol in clinical outcomes, obstetric and perinatal outcomes, and with a lower risk of OHSS. For those who want to get an effective and safe outcome, and a shorter treatment period, GnRH-ant is a suitable choice.

Optimizing estradiol level for gonadotrophin-releasing hormone antagonist initiation among patients with simple tubal factor infertility

OBJECTIVE

The aim of this study is to investigate the optimal estradiol (E₂) level on the day of gonadotropin-releasing hormone antagonist (GnRH-ant) initiation to maximize the clinical pregnancy rate (CPR) after fresh embryo transfer among patients with simple tubal factor infertility.

METHODS

A retrospective cohort study was conducted in the Reproductive Medicine Center, the Second Hospital of Hebei Medical University. A total of 1,493 IVF-ET cycles of patients diagnosed with single tubal factor infertility from August 2016 to August 2021 were included and equally allocated into five distinct groups according to the quintile serum E₂ levels on the day of GnRH-ant initiation. The five groups had similar baseline data except for antral follicle count.

RESULTS

The serum E ₂ level on GnRH-ant initiation day was determined as an independent predictor of clinical pregnancy after adjusting for confounding factors such as age, infertility duration, body mass index, cycle number, antral follicle count, and the number of transferred embryos. Through smooth curve fitting, we found that, with the increase of serum E₂ levels on the day of GnRH-ant initiation, CPR showed a trend of slight increase and then slight decrease. The maximal CPR was achieved when the serum E₂ level on GnRH-ant initiation day was 498 pg/ml. When E₂ was less than 498 pg/ml, the odds ratio (OR) of clinical pregnancy was 1.05 (95% CI: 1.00, 1.11, P = 0.0583). When E₂ was greater than 498 pg/ml, the OR of clinical pregnancy was 0.97 (95% CI: 0.95, 0.98, P = 0.0003). Furthermore, CPR remained high when E₂ was 436.8-658.6 pg/ml but declined significantly by more than 40% when E₂ was ≥ 894.4 pg/ml (P < 0.05).

CONCLUSIONS

The serum E₂ level should be considered as an adjuvant parameter for GnRH-ant initiation. The best E₂ value was 498 pg/ml, and GnRH-ant administration could be recommended to initiate when serum E₂ was 436.8-658.6 pg/ml. If GnRH-ant was initiated when serum E₂ was above 894.4 pg/ml, then the CPR after fresh embryo transfer may decline dramatically, and thus, cancellation of fresh embryo transfer and earlier initiation of GnRH-ant in future cycles should be considered.

Effects of artificial cycles with and without gonadotropin-releasing hormone agonist pretreatment on frozen embryo transfer outcomes in patients with adenomyosis

Gonadotropin-releasing hormone agonist (GnRH-a) is generally added to the improve pregnancy outcomes of hormone replacement therapy cycles among patients with adenomyosis. We aimed to investigate whether adding GnRH-a can result in better pregnancy outcomes. This retrospective analysis included 341 patients with adenomyosis who underwent frozen embryo transfer (FET) after in vitro fertilization (IVF). The control group was treated only with hormone replacement therapy cycles to prepare the endometrium, and GnRH-a was added to the study group before hormone administration to adjust the menstruation cycle. Based on the similar baseline values and embryological data, there was no significant difference in the clinical pregnancy rates (40.63% vs. 42.54%, P = 0.72) and live birth rates (23.75% vs. 23.75%, P = 0.74) of the control and study groups. Other secondary outcomes, including the rates of clinical miscarriage, ectopic pregnancy, preterm birth and term birth, were not significantly different between the two groups. Compared with the hormone replacement therapy cycle alone, GnRH-a downregulation based on a hormone replacement therapy cycle may not increase the rate of clinical pregnancy or live birth of IVF-ET with FET among infertile patients with adenomyosis.

Cumulative live birth rates between GnRH-agonist long and GnRH-antagonist protocol in one ART cycle when all embryos transferred: real-word data of 18,853 women from China

BACKGROUND

A consensus has been reached on the preferred primary outcome of all infertility treatment trials, which is the cumulative live birth rate (CLBR). Some recent randomized controlled trials (RCTs) and retrospective studies have compared the effectiveness of GnRH-antagonist and GnRH-agonist protocols but showed inconsistent results. Studies commonly used conservative estimates and optimal estimates to described the CLBR of one incomplete assisted reproductive technology (ART) cycle and there are not many previous studies with data of the complete cycle to compare CLBRs in GnRH-antagonist versus GnRH-agonist protocols.

METHODS

A total of 18,853 patients have completed their first IVF cycle including fresh and subsequent frozen-thawed cycles during 2016-2019, 16,827 patients were treated with GnRH-a long and 2026 patients with GnRH-ant protocol. Multivariable logistic analysis was used to evaluate the difference of GnRH-a and GnRH-ant protocol in relation to CLBR. Utilized Propensity Score Matching(PSM) for sampling by up to 1:1 nearest neighbor matching to adjust the numerical difference and balance the confounders between groups.

RESULTS

Before PSM, significant differences were observed in baseline characteristics and the CLBR was 50.91% in the GnRH-a and 33.42% in the GnRH-ant (OR = 2.07; 95%CI: 1.88-2.28; P < 0.001). Stratified analysis showed the CLBR of GnRH-ant was lower than GnRH-a in suboptimal responders(46.89 vs 27.42%, OR = 2.34, 95%CI = 1.99-2.74; P < 0.001) and no differences of CLBR were observed in other patients between protocols. After adjusting for potential confounders, multivariable logistic analysis found the CLBR of GnRH-ant group was lower than that of GnRH-a group (OR = 2.11, 95%CI:1.69-2.63, P < 0.001). After PSM balenced the confounders between groups, the CLBR of GnRH-a group was higher than that of GnRH-ant group in suboptimal responders((38.61 vs 28.22%, OR = 1.60, 95%CI = 1.28-1.99; P < 0.001) and the normal fertilization rate and number of available embryo in GnRH-a were higher than these of GnRH-ant groups in suboptimal responders (77.39 vs 75.22%; 2.86 ± 1.26 vs 2.61 ± 1.22; P < 0.05). No significant difference was observed in other patients between different protocols.

CONCLUSIONS

It is crucial to optimize the utilization of protocols in different ovarian response patients and reconsider the field of application of GnRH-ant protocols in China.