GnRH antagonist for patients with polycystic ovary syndrome undergoing controlled ovarian hyperstimulation for in vitro fertilization and embryo transfer in fresh cycles

GnRH antagonist impairs the process of embryo implantation by inhibiting motility of endometrial stromal cells through reducing c-kit expression

BACKGROUND

It has been recognized that the gonadotropin-releasing hormone antagonist (GnRH-ant) protocol has a detrimental effect on clinical outcomes compared to the GnRH agonist (GnRH-a) protocol during in vitro fertilization-fresh embryo transfer (IVF-ET) cycles. However, the related mechanisms were unclear.

METHODS

A total of 18,561 patients, who underwent fresh IVF-ET cycles in the Center for Assisted Reproduction of Jiangxi Maternal and Child Health Hospital from January 2014 to September 2021, were retrospectively analyzed. The propensity score matching (PSM) technique was used to control for confounding factors between the GnRH-ant and GnRH-a groups. Human endometrial stromal cells (hESCs) were collected for primary culture and treated with relevant receptor antagonists and activators. RT-PCR, Western Blot, immunofluorescence staining, cell migration and adhesion assays, and animal experiments were employed to elucidate the molecular mechanism by which GnRH antagonist affects the migration and adhesion ability of hESCs.

RESULTS

There was no statistical difference between the two groups in terms of baseline characteristics after matching basal status by propensity score matching. The result showed that the endometrial thickness (10.4 ± 2.35 vs. 11.03 ± 2.61 mm, p < .001) on trigger day was significantly lower in the GnRH-ant group. Compared with the GnRH-a protocol, the implantation rate (39.71% vs. 50.36%, p < .001), biochemical pregnancy rate (64.26% vs. 72.7%, p < .001), clinical pregnancy rate (56.39% vs. 65.24%, p < .001), live birth rate (45.25% vs. 56.1%, p < .001) in the GnRH-ant group were significantly decreased. Contrarily, the rate of early miscarriage in the GnRH-ant group (13.95% vs. 9.04%, p < .001) was higher than in the GnRH-a group. Furthermore, after treating with GnRH-ant, hESCs showed a reduced expression of HOXA10 and MMP-9 proteins, and a weakened migration ability. Subsequently, by establishing the co-culture system of hESCs and JAR trophoblast spheroids, we found that GnRH-ant inhibited the adhesion and invasion ability of trophoblast cells. Moreover, we also found a decreased expression and phosphorylation of c-kit receptor in decidualized hESCs after treating with GnRH-ant. Similar results as observed above were also confirmed when inhibiting the activation of c-kit receptor by imatinib.

CONCLUSIONS

GnRH-ant could reduce the motility of hESCs by inhibiting the expression and activation of the C-kit receptor, which impaired the process of embryo implantation.

Do basal Luteinizing Hormone and Luteinizing Hormone/Follicle-Stimulating Hormone Ratio Have Significance in Prognosticating the Outcome of In vitro Fertilization Cycles in Polycystic Ovary Syndrome?

Context:

Tonic hypersecretion of luteinizing hormone (LH) appears to impact both fertility and pregnancy outcomes in women with polycystic ovary syndrome (PCOS).

Aim:

Whether high basal day 2/3 serum LH levels and day 2/3 LH/follicle-stimulating hormone (FSH) ratio affect in vitro fertilization (IVF) cycle outcomes in PCOS patients undergoing controlled ovarian hyperstimulation using gonadotropin-releasing hormone (GnRH) antagonists.

Settings and Design:

A retrospective cohort study was conducted in Assisted Reproductive Technique Center, Department of Obstetrics and Gynaecology, at a tertiary care institute, on PCOS patients undergoing IVF/intracytoplasmic sperm injection (ICSI) using GnRH antagonist protocol with human chorionic gonadotropin trigger between January 2014 to December 2019.

Methods and Material:

Data related to patient's age, body mass index, day 2/3 serum FSH, serum LH, day 2/3 LH/FSH ratio, and infertility treatment-related variables were collected from the patient record files. IVF cycle characteristics, number of oocytes retrieved, number of embryos transferred were also recorded. The clinical pregnancy rate per embryo transfer was calculated.

Statistical Analysis:

Statistical software SPSS IBM version 24.0 was used to analyze the data. Descriptive statistics such as mean, standard deviation , and range values were calculated. To compare the difference between the groups, the paired t-test was applied for continuous variables and the Chi-square test for categorical variables. A value of P < 0.05 was considered statistically significant.

Results:

High basal day 2/3 LH level and day 2/3 LH/FSH ratio have no statistically significant effect on embryos formed, embryo transferred, and clinical pregnancy rate. However, fertilization rates were significantly less in these groups.

Conclusion:

The elevated basal day 2/3 LH and LH/FSH ratio do not impair the outcome of GnRH antagonist protocol treated IVF/ICSI cycles in PCOS women.

Influence of GnRH antagonist in reproductive women on in vitro fertilization and embryo transfer in fresh cycles

The aim of the present study was to evaluate the influence of a gonadotropin-releasing hormone (GnRH) antagonist compared with a GnRH agonist on in vitro fertilization (IVF) cycle outcome in reproductive women. The characteristics of treatment and outcomes of pregnancy were retrospectively compared between the antagonist (GnRH-A, antagonist group) and agonist (GnRH-a, agonist group) regimens. The area under the curve (AUC) of receiver operating characteristic (ROC) curves was also used to evaluate whether the endometrial thickness (cm), progesterone (P) level (ng/ml) and estradiol (E₂) level (pg/ml) on the day of human chorionic gonadotropin (hCG) administration (hCG day) had the ideal sensitivity and specificity for predicting clinical pregnancy. There were no significant differences in the baseline profiles of luteinizing hormone, E₂ and P between the GnRH-A and GnRH-a groups (P=0.646, 0.224 and 0.119, respectively). However age, body mass index and follicle stimulating hormone (FSH) level significantly differed between the two groups (P<0.001, =0.025 and <0.001, respectively). Regarding treatment, there were significant differences in the stimulation duration (recombinant FSH days of usage), dose of gonadotrophins, E₂, and P levels on hCG day, endometrial thickness on hCG day, mean number of total oocytes retrieved, mean number of two pronuclei oocytes, mean number of embryos available and mean number of embryos transferred (all P<0.001). The rate of clinical pregnancy was lower with the GnRH antagonist than with the GnRH agonist (P<0.001). Additionally, the live birth rate in the GnRH-A group was significantly lower than that in the GnRH-a group (P<0.001). The rate of ectopic pregnancy did not differ significantly between the treatment groups (P=0.840). However, the rate of ovarian hyperstimulation syndrome (OHSS) in group GnRH-A was significantly lower than that in group GnRH-a (P=0.039). Therefore, in the present series of patients who underwent IVF embryo transfer cycles, a GnRH antagonist protocol was associated with significantly lower rates of clinical pregnancy and live birth compared with a GnRH agonist protocol; however, the rate of OHSS was significantly lower with GnRH antagonist compared with GnRH agonist. Furthermore, the results of the influence of endometrial thickness on clinical pregnancy, based on the ROC curve (AUC), demonstrated that the AUC was 0.553 [95% confidence interval (CI): 0.521-0.585], and with a cutoff of 9.25 cm, the Youden index [sensitivity-(1-specificity)] was 0.085. The results of the influence of E₂ level on hCG day on the clinical pregnancy rate revealed an AUC of 0.613 (95% CI: 0.581-0.644), and with a cutoff of 1,520 pg/ml, the Youden index was 0.184. The results of the influence of P level on hCG day (ng/ml) on the clinical pregnancy rate revealed an AUC of 0.526 (95% CI: 0.494-0.558), and with a cutoff of 0.415 ng/ml, the Youden index was 0.061. These results of the ROC curve analyses demonstrated that neither the endometrial thickness nor the E₂ and P levels on hCG day had the ideal sensitivity or specificity for predicting clinical pregnancy.