hCG Triggering in ART: An Evolutionary Concept

Reproductive outcomes of dual trigger therapy with GnRH agonist and hCG versus hCG trigger in women with diminished ovarian reserve: a retrospective study

BACKGROUND

Diminished ovarian reserve (DOR) is one of the obstacles affecting the reproductive outcomes of patients receiving assisted reproductive therapy. The purpose of this study was to investigate whether dual trigger, including gonadotropin-releasing hormone agonist (GnRHa) and human chorionic gonadotropin (hCG), can improve pregnancy outcomes in patients with DOR undergoing in vitro fertilization (IVF) cycles using mild stimulation protocols.

METHODS

A total of 734 patients with DOR were included in this retrospective study. Patients were divided into a recombinant hCG trigger group and a dual trigger group (hCG combined with GnRHa) according to the different trigger drugs used. The main outcome measures included the number of oocytes retrieved, the fertilization rate, the number of transferable embryos, the implantation rate, the clinical pregnancy rate, the miscarriage rate, the live birth rate (LBR), and the cumulative live birth rate (CLBR). Generalized linear model and logistic regression analyses were performed for confounding factors.

RESULTS

There were 337 cycles with a single hCG trigger and 397 cycles with dual trigger. The dual trigger group demonstrated significantly higher numbers of retrieved oocytes [3.60 vs. 2.39, adjusted β = 0.538 (0.221-0.855)], fertilized oocytes [2.55 vs. 1.94, adjusted β = 0.277 (0.031-0.523)] and transferable embryos [1.22 vs. 0.95, adjusted β = 0.162 (-0.005-0.329)] than did the hCG trigger group, whereas no significant difference in the fertilization rate was observed between the two groups. Moreover, the embryo transfer cancellation rate (35.5% vs. 43.9%) was obviously lower in the dual trigger group. Among the fresh embryo transfer cycles, the implantation rate, clinical pregnancy rate, miscarriage rate and live birth rate were similar between the two groups. After controlling for potential confounding variables, the trigger method was identified as an independent factor affecting the number of oocytes retrieved but had no significant impact on the CLBR.

CONCLUSIONS

Dual triggering of final oocyte maturation with hCG combined with GnRHa can significantly increase the number of oocytes retrieved in patients with DOR but has no improvement effect on the implantation rate, clinical pregnancy rate or LBR of fresh cycles or on the CLBR.

The Implications of Double Human Chorionic Gonadotropin (hCG) Trigger on a Pseudo-Empty Follicle Syndrome Patient Seeking Infertility Treatment Through Assisted Reproductive Technology (ART)

In the field of assisted reproductive technology (ART), empty follicle syndrome (EFS) is a known condition in which no oocytes are found despite adequate follicular development, which leads to a troublesome situation for patients seeking infertility treatment. In this case study, an EFS patient seeking treatment for infertility at an in vitro fertilization (IVF) clinic was examined to determine the effects of employing a double human chorionic gonadotropin (hCG) trigger. The final oocyte maturation and retrieval are induced by using the double hCG trigger, which includes giving two doses of hCG. In this particular patient, the study looks at the results of follicular development, oocyte retrieval, fertilization rates, embryo quality, and pregnancy rates. The conclusion provides information on how well the double hCG trigger affects treatment outcomes for EFS patients. According to the results of this case study, the two-stage hCG trigger procedure is suggested to enhance the results of oocyte retrieval in the uncategorized EFS patient. In all cycles after the procedural change, the double trigger's application led to effective oocyte maturation and retrieval. The study also showed that the double hCG trigger procedure had no negative consequences on patient safety or ovarian response. There were also no signs of ovarian hyperstimulation syndrome (OHSS) or any other problems. Due to the higher likelihood of oocyte retrieval, the patient also reported better emotional health and less anxiety during subsequent treatment cycles. The positive result of this case study demonstrates the potential advantages of a double hCG trigger procedure in pseudo-EFS patients receiving IVF treatment. When handling EFS cases, this modified strategy may be used as a potential answer by infertility clinics. The effectiveness and safety of the double hCG trigger procedure still need to be confirmed by doing randomized controlled trials on larger populations in order to validate the result.

Female BMI and Body Weight Is Not Associated with Oocyte Yield and Maturation in hCG, Agonist or Dual Trigger Cycles: A Large Observational Study including 5000 Cycles

BACKGROUND

Triggering final oocyte maturation is a key step of ovarian stimulation. Although previous studies demonstrated a negative association between female BMI and serum hCG levels, little evidence is available regarding the association between oocyte yield and patients' BMI. The scope of the current study was to examine whether the efficiency of the r-hCG and triptorelin to trigger final oocyte maturation may be associated with patients' BMI or weight.

METHODS

This is a retrospective observational study including 5190 ovarian stimulation cycles performed between January 2019 and September 2022 in the Reproductive Medicine Department of Dexeus University Hospital. Cycles were analyzed according to the type of trigger (triptorelin vs. r-hCG vs. dual). The primary outcome measures were oocyte maturation rate (MII/oocytes) and FOI (oocytes/AFC); secondary outcomes were oocyte and MII yield.

RESULTS

Multivariable regression analysis, adjusting for confounding factors, demonstrated that BMI was not associated with oocyte maturation rate (OR: 1.00 [95%CI: 0.99; 1.01]), FOI (Beta 0.52 [95%CI: -0.49; 1.54]), number of oocytes (Beta 0.02 [95%CI: -0.08; 0.13]) or MIIs (Beta 0.01 [95%CI: -0.08; 0.10]) retrieved. Similarly, all analyses conducted considering patients' weight failed to reveal any association.

CONCLUSION

Our study demonstrates that, independent of the type of trigger, patients' BMI and weight are not associated with oocyte yield, maturation, or FOI.

Granulocyte colony stimulating factor versus human chorionic gonadotropin for recurrent implantation failure in intra cytoplasmic sperm injection: a randomized clinical trial

BACKGROUND

Repeated implantation failure (RIF) is defined as the case whereby the transferred embryos fail to implant after several attempts of In vitro fertilization (IVF) which causes a profound impact on the quality of life and financial burden. Some clinical studies have confirmed that Granulocyte colony-stimulating factor (G-CSF) and human chorionic gonadotropin (HCG) can improve pregnancy outcomes and implantation rates. Hence, our study aims to compare the efficacy of G-CSF and HCG on pregnancy outcomes in RIF women who undergo intra-cytoplasmic sperm injection (ICSI).

METHODS

This randomized, single-blinded study was conducted et al.-Azhar University Hospitals, Cairo, Egypt, between 10^th October 2020 and 20^th December 2020. The study included 100 women aged 20-43 years old undergoing ICSI cycles, with a history of RIF. Patients were divided randomly into two groups: group (1): included 50 patients injected with 500 IU of intrauterine HCG on embryo transfer day, and group (2): Included 50 patients injected with G-CSF on the embryo transfer day.

RESULTS

In 100 RIF women, we found a significant improvement in pregnancy outcomes favoring G-CSF over HCG including implantation rate, chemical pregnancy, and clinical pregnancy (P < 0.0001, P = 0.0003, and P = 0.0006, respectively).

CONCLUSION

For the first time, we demonstrated a significant improvement in pregnancy outcomes favoring G-CSF over HCG in terms of implantation rate, chemical pregnancy, and clinical pregnancy.

TRIAL REGISTRATION

The study was registered on Pan African Clinical Trials Registry with the following number: PACTR202010482774275 and was approved on 2^nd October 2020.

Plumeria acuminata: A Systematic in vivo Evaluation for Its Anti-ovulatory and Anti-Implantation Features

Background:

Fertility control becomes necessary for under-developed and developing nations for the betterment of the economy, environment, and society. Plant Plumeria acuminata, “Temple tree or Frangipani”, of the Apocynaceae family has exhibited several activities similar to contraceptive medicine and is widely distributed in India.

Objective:

Present investigation aimed to study the anti-ovulatory and anti-implantation activities of ethanolic extract from P. acuminata leaves and roots in Wistar rats.

Methods:

Ethanolic extracts of P. acuminata leaves and roots were subjected to qualitative phytochemical analysis and acute toxicity test. Immature female rats were used to explore anti-ovulatory characteristics administering HCG as a standard ovulation-inducing drug. Mated females were used for exploring anti-implantation characteristics. Levonorgestrel and Ethinylestradiol were administered as standard anti-implantation drugs. Morphological, hematological, hormonal, and histological examinations were performed.

Results:

LD50 value i.e., 2000 mg/kg from acute toxicity test resulted in the selection of 100, 200, and 400 mg/kg dose values for both leaf and root extracts. Treatment with these brought ~2-54%, ~5-48%, and ~1-68% changes respectively in the hormonal, growth factors’ and cytokines’ profile. Ovarian histology revealed restricted follicle maturation and ovulation whereas uterine histology unveiled a ~5-28% decrease in the endometrium thickness making it unreceptive for implantation after treatment with PAL and PAR extracts.

Conclusion:

Anti-ovulatory and anti-implantation results obtained here can be attributed to the presence of plumericin, sterol as well as triterpene groups of phytochemicals from ethanolic extracts of leaves and roots, making them potent contestants for studies on future contraceptive medicines.

Tie1 contributes to the development of ovarian hyperstimulation syndrome under the regulation of EGR1 in granulosa cells

The expression of tyrosine kinase with immunoglobulin-like and epidermal growth factor-like domains 1 (Tie1), a transmembrane protein expressed almost exclusively by endothelial cells, has been reported in granulosa cells. However, its significance in ovarian hyperstimulation syndrome (OHSS), which can occur after the injection of gonadotropins in infertile women undergoing controlled ovarian stimulation, is unknown. Here, we report significantly increased Tie1 and vascular endothelial growth factor (VEGF) expression in cultured granulosa cells from OHSS patients, as well as ovaries from rats with experimentally established OHSS, compared to controls, with the levels of both proteins also increasing in granulosa and SVOG cells (a nontumorigenic human granulosa-lutein cell line) treated with an acute dose of human chorionic gonadotropin (hCG). Tie1 silencing abolished the hCG-induced VEGF level in SVOG cells and attenuated the progression of OHSS in rats, as determined by histological analysis. Further studies in SVOG cells revealed that the hCG-induced upregulation of Tie1 expression involved the phosphoinositide 3-kinase/protein kinase B signaling pathway. We also report that early growth response protein 1 (EGR1), whose expression was also upregulated by hCG, bound directly to the Tie1 promoter and activated its transcription. Taken together, our results indicate that Tie1 may be a therapeutic target in cases of moderate-to-severe OHSS. Further studies are needed to address its clinical relevance.

IVF protocol efficacy in women with expected suboptimal response depending on ovary stimulation mode

INVESTIGATION OBJECTIVE

IVF protocol efficacy estimation in women with expected suboptimal response depending on ovary stimulation mode.

MATERIALS AND TECHNIQUE

A randomized controlled study embracing results of 51 IVF cycle in women with ovary suboptimal response. The suboptimal response prognostic analysis was performed basing on ≤9 oocyte cumulus complexes obtained in previous IVF programs, the presence of no less than 5-9 antral follicles in both oocytes and amount of anti-Mullerian Hormone ≥0,8 ng/mL. In Group I (n = 25), the stimulation was performed by recombinant corifollitropin alfa combined with highly purified urinary gonadotropin, while in Group II (n = 26) it was made by means of recombinant follitropin/lutropin alfa within the protocol of applying gonadotropin-releasing hormone antagonists.

RESULTS

The total gonadotropin dose in Group II patients was authentically lower compared to Group I (p˂,01). No statistical difference between the two studied groups was detected concerning the number of obtained oocytes, 2pn zygote, good-quality transferred embryos and clinical pregnancy rate (p>.05). Embryo cryopreservation was performed only for group-II patients.

CONCLUSION

Corifollitropin alfa administration combined with highly purified menotropin in IVF cycles for suboptimal responders is quite effective, however, this strategy has no preference over other stimulation modes. The strategy of using recombinant follitropin/lutropin alfa can be promotive to IVF outcomes for suboptimal responders by means of embryo banking. ClinicalTrials.gov Identifier: NCT03177538.

Gonadotropin releasing hormone agonist triggering for in vitro maturation cycles

The objective was to evaluate the outcomes of in vitro maturation (IVM) cycles using gonadotropin releasing hormone agonist (GnRH-ag) triggering. A retrospective cohort of IVM cycles from January 2015 to December 2019 in a single university-affiliated centre was examined. Main outcome measures were: (i) IVM maturation rate; and (ii) IVM maturation result. Secondary outcome measures were: (i) metaphase II (MII) rate on the day of egg retrieval; (ii) final MII maturation rate; and (iii) pregnancy rates. A total of 98 IVM cycles were performed during the study period: 50 (51%) were triggered with GnRH-ag (17 received FSH priming and 33 did not) and 48 cycles (49%) were triggered by hCG (37 with FSH priming and 11 without). A significant (p = 0.01) difference was noticed in maturation rate on egg retrieval day, in favour of the GnRH-ag group, although not in the final maturation rate achieved. Pregnancy rates were comparable between treatment sub-groups. GnRH-ag triggering in IVM cycles is an optional triggering mode and can be considered an acceptable option, especially when fertility preservation is a concern. GnRH agonists resulted in higher maturation rate on day of oocyte retrieval, but no difference in the total maturation rate.

Intrauterine perfusion immunotherapies in recurrent implantation failures: Systematic review

Studies have investigated the gestational outcomes of new immunological therapies in the treatment of patients with recurrent implantation failure (RIF) in assisted reproductive technology (ART). The objective of this article is to assess the current state of evidence available in the literature on intrauterine perfusion immunotherapies in women undergoing ART treatments. By considering the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), the authors performed systematic review by searching the databases of PubMed/MEDLINE and Scopus using the following key words: "recurrent implantation failure," "intrauterine infusion," "Platelet-Rich Plasma (PRP)," "Peripheral Blood Mononuclear Cells (PBMC)," "Granulocyte Colony-Stimulating Factor (G-CSF)," and "Human Chorionic Gonadotropin (hCG)." The authors analyzed the indications and the impact of new immunological therapies with intrauterine infusions on the pregnancy outcomes of patients undergoing ART. PRP, PBMC, G-CSF, and hCG were the four most used immunological therapies with intrauterine infusion. These new therapies appear to improve the results of ART treatments in cases of RIF. However, the small number of studies does not allow definitive conclusions about the effectiveness of these therapies.

Endometrial expression of receptivity markers subject to ovulation induction agents

PURPOSE

Implantation rates differ according to ovulation induction agents in ART. This study investigates the different local endometrial effects of LH- versus hCG-induced ovulation.

METHODS

Endometrial stromal cells from healthy patients were cultured with hCG or LH in different concentrations, supplemented with 250 ng/mL hCG and progesterone after 2 and 5 days. In addition after decidualization induction, cells were treated with hCG (50 or 250 ng/mL) or LH (10 or 50 ng/mL) for 3 days. Receptivity markers expression was evaluated by real-time quantitative PCR on day 3 and 6.

RESULTS

On day 3, non-decidualized cells treated with LH showed an increased expression of IGFBP1, IL-8 and CXCL12 compared to hCG. The expression pattern changed on day 6, where cells treated with hCG showed higher expression of implantation markers compared to LH-treated cells. Furthermore, on day 3, decidualized cells treated with hCG250 showed an increased IL8 and CXCL12 expression compared to LH10.

CONCLUSIONS

LH seems to modulate the local endometrial expression of receptivity markers earlier compared to hCG; however, the effect is not sustained over time in cells without prior decidualization. Though, in decidualized cells, pattern changed and an earlier positive effect of hCG was shown on IL-8 and CXCL12.

Novel Concepts for Inducing Final Oocyte Maturation in In Vitro Fertilization Treatment

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.