Assessing predictors for the success of GnRH antagonist protocol in reproductive women in IVF/ICSI - in fresh cycles

Predictors of success after in vitro fertilization

The last few decades have witnessed a rise in the global uptake of in vitro fertilization (IVF) treatment. To ensure optimal use of this technology, it is important for patients and clinicians to have access to tools that can provide accurate estimates of treatment success and understand the contribution of key clinical and laboratory parameters that influence the chance of conception after IVF treatment. The focus of this review was to identify key predictors of IVF treatment success and assess their impact in terms of live birth rates. We have identified 11 predictors that consistently feature in currently available prediction models, including age, duration of infertility, ethnicity, body mass index, antral follicle count, previous pregnancy history, cause of infertility, sperm parameters, number of oocytes collected, morphology of transferred embryos, and day of embryo transfer.

The effect of luteinizing hormone changes in GnRH antagonist protocol on the outcome of controlled ovarian hyperstimulation and embryo transfer

BACKGROUD

To investigate the effect of Luteinizing hormone (LH) level changes on the outcomes of controlled ovarian hyperstimulation (COH) and embryo transfer (ET) in gonadotropin-releasing hormone antagonist (GnRH-ant) protocol.

METHODS

A total of 721 patients undergoing GnRH-ant protocol COH for the first IVF/ICSI cycles were retrospectively analyzed. COH process were divided into 2 stages, before (stage 1) and after (stage 2) the GnRH-ant initiation, and each with 5 groups basing on LH levels: LH decreased more than 50% (groups A1, A2), decreased 25-50% (groups B1, B2), change less than 25% (groups C1, C2), increased 25-50% (groups D1, D2), and increased more than 50% (groups E1, E2).

RESULTS

There were no significant differences among groups of stage1 regarding COH and ET outcomes. For stage 2, the more obvious the decrease of LH level, the more the number of oocytes retrieved, mature oocytes, fertilized oocytes, embryos cleavaged and the numbers of embryo available (P < 0.05), but without significant differences regarding ET outcomes. We also found the freeze-all rate in Group A2 was higher (P < 0.001).

CONCLUSION

LH level changes before GnRH-ant addition were not related to COH and ET outcomes. LH level changes after the addition of GnRH-ant were related to the outcome of COH, and no significant differences were found relating to ET outcomes.

Effects of increasing serum luteinizing hormone levels during early phase of the gonadotropin-releasing hormone antagonist protocol on clinical outcomes of the in vitro fertilization cycle

OBJECTIVE

To determine the effects of changes in serum luteinizing hormone (LH) levels in the early stages of the gonadotropin-releasing hormone antagonist (GnRH-A) protocol on in vitro fertilization and embryo transfer/intracytoplasmic sperm injection clinical outcomes.

METHODS

Data from 2116 fresh embryo transfer cycles with the GnRH-A protocol were retrospectively analyzed. Patients were divided into two groups, ΔLH-increased and ΔLH-decreased, according to changes in serum LH levels on the day of GnRH-A addition compared with that on the start day of ovarian stimulation. Patients in whom ΔLH increased were categorized according to early-onset LH increases (serum LH level ≥10 mIU/mL or twice the baseline).

RESULTS

ΔLH increased and decreased in 14.9% and 85.1% of patients, respectively. The fertilization rate was lower, and fewer oocytes were retrieved in patients with increased ΔLH compared to those with decreased ΔLH (p < .05). The number of AFC, oocytes retrieved, and AMH in patients with early-onset ΔLH increase was lower between the subgroups (p < .05). There were no significant differences in clinical pregnancy, early abortion, biochemical pregnancy, and live birth rates between the groups and subgroups (p > .05).

CONCLUSIONS

Early increases in LH levels during GnRH-A protocol might affect the number of oocytes retrieved, but not the clinical outcomes.

Population PK-PD-PD Modeling of Recombinant Follicle Stimulating Hormone in In Vitro Fertilization/Intracytoplasmic Sperm Injection: Implications on Dosing and Timing of Gonadotrophin Therapy

This study aimed to characterize an interactive and clinically applicable population pharmacokinetic-pharmacodynamic-pharmacodynamic (PK-PD-PD) model describing follicle-stimulating hormone (FSH)-inhibin B-oocyte relationship in women undergoing assisted reproduction with in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). The study was a prospective analysis of 25 healthy women undergoing IVF/ICSI using gonadotropin-releasing hormone (GnRH) antagonist protocol. The developed model used the FSH PK profiles to predict both inhibin B (first PD end point) and oocyte retrieval (second PD end point). The modeling framework involved 2 stages. First, the FSH-inhibin B model was developed by the simultaneous approach and applied to estimate the individual area under the inhibin B-time curve (AUC_Inhb ) at the end of stimulation cycles that varied in length in each woman. In the second stage, the estimated AUC_Inhb was introduced as a link covariate to predict oocyte retrieval and response category. The population FSH-inhibin B model was described as 3 submodels; PK (exogenous), endogenous, and inhibin B PD models. Weight was the main determinant of both endogenous and exogenous FSH exposures. GnRH antagonist therapy was a significant time-varying covariate when tested against the endogenous FSH production rate (P < .001). AUC_Inhb could be predicted with women's age and weight. Log-transformed AUC_Inhb was a significant covariate when tested against oocyte retrieval (P < .001). Simulations concluded a target AUC_Inhb of 144-303 ng·h/mL for optimal ovarian response. The GnRH antagonist was better started on day 7 of the cycle. Covariate-based dosing suggests lower recombinant follicle-stimulating hormone requirements in a thin and/or young population. An interactive web application "GonadGuide" was developed to facilitate the application in clinical practice.

A nomogram predicting clinical pregnancy in the first fresh embryo transfer for women undergoing in vitro fertilization and intracytoplasmic sperm injection (IVF/ICSI) treatments

The extent to which factors affect the probability of clinical pregnancy in the first fresh embryo transfer after assisted conception is unknown. In order to examine the predictors of clinical pregnancy, a retrospective cohort study was launched between January 1, 2013 and December 31, 2016 in four infertility clinics including 19 837 in vitro fertilization and intracytoplasmic sperm injection (IVF/ICSI) fresh cycles with known outcomes and relevant records. A multivariable logistic regression was used to select the most significant predictors in the final nomogram for predicting clinical pregnancy. Furthermore, the model was validated by an independent validation set and the performance of the model was evaluated by the receiver operating characteristic (ROC) curves along with the area under the ROC curve (AUC) and calibration plots. In a training set including 17 854 participants, we identified that female age, tubal factor, number of embryos transferred, endometrial thickness and number of good-quality embryos were independent predictors for clinical pregnancy. We developed a nomogram using these five factors and the predictive ability was 0.66 for AUC (95% CI 0.64–0.68), which was independently validated in the validation set (AUC=0.66, 95% CI 0.65–0.68). Our results show that some specific factors can be used to provide infertile couples with an accurate assessment of clinical pregnancy following assisted conception and facilitate to guide couples and clinicians.