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Kastora SL, Gkova G, Stavridis K, Balachandren N, Kastoras A, Karakatsanis A, Mavrelos D. Comparison of luteal support protocols in fresh IVF/ICSI cycles: a network meta-analysis. Sci Rep 2024; 14:14492. [PMID: 38914570 PMCID: PMC11196689 DOI: 10.1038/s41598-024-64804-z] [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: 09/25/2023] [Accepted: 06/13/2024] [Indexed: 06/26/2024] Open
Abstract
Despite the proven superiority of various luteal phase support protocols (LPS) over placebo in view of improved pregnancy rates in fresh cycles of IVF (in vitro fertilization) and ICSI (intracytoplasmic sperm injection) cycles, there is ongoing controversy over specific LPS protocol selection, dosage, and duration. The aim of the present study was to identify the optimal LPS under six core aspects of ART success, clinical pregnancy, live birth as primary outcomes and biochemical pregnancy, miscarriage, multiple pregnancy, ovarian hyperstimulation syndrome (OHSS) events as secondary outcomes. Twelve databases, namely Embase (OVID), MEDLINE (R) (OVID), GlobalHealth (Archive), GlobalHealth, Health and Psychosocial Instruments, Maternity & Infant Care Database (MIDIRS), APA PsycTests, ClinicalTrials.gov, HMIC Health Management Information Consortium, CENTRAL, Web of Science, Scopus and two prospective registers, MedRxiv, Research Square were searched from inception to Aug.1st, 2023, (PROSPERO Registration: CRD42022358986). Only Randomised Controlled Trials (RCTs) were included. Bayesian network meta-analysis (NMA) model was employed for outcome analysis, presenting fixed effects, odds ratios (ORs) with 95% credibility intervals (CrIs). Vaginal Progesterone (VP) was considered the reference LPS given its' clinical relevance. Seventy-six RCTs, comparing 22 interventions, and including 26,536 participants were included in the present NMA. Overall CiNeMa risk of bias was deemed moderate, and network inconsistency per outcome was deemed low (Multiple pregnancy χ2: 0.11, OHSS χ2: 0.26), moderate (Clinical Pregnancy: χ2: 7.02, Live birth χ2: 10.95, Biochemical pregnancy: χ2: 6.60, Miscarriage: χ2: 11.305). Combinatorial regimens, with subcutaneous GnRH-a (SCGnRH-a) on a vaginal progesterone base and oral oestrogen (OE) appeared to overall improve clinical pregnancy events; VP + OE + SCGnRH-a [OR 1.57 (95% CrI 1.11 to 2.22)], VP + SCGnRH-a [OR 1.28 (95% CrI 1.05 to 1.55)] as well as live pregnancy events, VP + OE + SCGnRH-a [OR 8.81 (95% CrI 2.35 to 39.1)], VP + SCGnRH-a [OR 1.76 (95% CrI 1.45 to 2.15)]. Equally, the progesterone free LPS, intramuscular human chorionic gonadotrophin, [OR 9.67 (95% CrI 2.34, 73.2)] was also found to increase live birth events, however was also associated with an increased probability of ovarian hyperstimulation, [OR 1.64 (95% CrI 0.75, 3.71)]. The combination of intramuscular and vaginal progesterone was associated with higher multiple pregnancy events, [OR 7.09 (95% CrI 2.49, 31.)]. Of all LPS protocols, VP + SC GnRH-a was found to significantly reduce miscarriage events, OR 0.54 (95% CrI 0.37 to 0.80). Subgroup analysis according to ovarian stimulation (OS) protocol revealed that the optimal LPS across both long and short OS, taking into account increase in live birth and reduction in miscarriage as well as OHSS events, was VP + SCGnRH-a, with an OR 2.89 [95% CrI 1.08, 2.96] and OR 2.84 [95% CrI 1.35, 6.26] respectively. Overall, NMA data suggest that combinatorial treatments, with the addition of SCGnRH-a on a VP base result in improved clinical pregnancy and live birth events in both GnRH-agonist and antagonist ovarian stimulation protocols.
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Affiliation(s)
- Stavroula L Kastora
- UCL EGA Institute for Women's Health, University College London, Medical School Building, Room G15, 86-96 Chenies Mews, 74 Huntley Street, London, WC1E 6HX, UK.
- Department of Obstetrics and Gynaecology, Barnet Hospital, Royal Free London NHS Foundation Trust, London, UK.
| | - Grigoria Gkova
- Department of Obstetrics and Gynaecology, Barnet Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Konstantinos Stavridis
- 2nd Department of Obstetrics and Gynaecology, "Aretaieion" University Hospital, Athens, Greece
| | - Neerujah Balachandren
- UCL EGA Institute for Women's Health, University College London, Medical School Building, Room G15, 86-96 Chenies Mews, 74 Huntley Street, London, WC1E 6HX, UK
| | - Athanasios Kastoras
- Reproductive Medicine Unit, "Leto" Maternity Hospital, Mouson Str. 7-13, 11524, Athens, Greece
| | - Andreas Karakatsanis
- Department of Surgical Sciences, Faculty of Medicine, Uppsala University, Uppsala, Sweden
- Section for Breast Surgery, Department of Surgery, Uppsala University Hospital (Akademiska), Uppsala, Sweden
| | - Dimitrios Mavrelos
- UCL EGA Institute for Women's Health, University College London, Medical School Building, Room G15, 86-96 Chenies Mews, 74 Huntley Street, London, WC1E 6HX, UK
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Liu X, Chen Z, Ji Y. Construction of the machine learning-based live birth prediction models for the first in vitro fertilization pregnant women. BMC Pregnancy Childbirth 2023; 23:476. [PMID: 37370040 DOI: 10.1186/s12884-023-05775-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 06/11/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND This study was to conduct prediction models based on parameters before and after the first cycle, respectively, to predict live births in women who received fresh or frozen in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) for the first time. METHODS This retrospective cohort study population consisted of 1,857 women undergoing the IVF cycle from 2019 to 2021 at Huizhou Municipal Central Hospital. The data between 2019 and 2020 were completely randomly divided into a training set and a validation set (8:2). The data from 2021 was used as the testing set, and the bootstrap validation was carried out by extracting 30% of the data for 200 times on the total data set. In the training set, variables are divided into those before the first cycle and after the first cycle. Then, predictive factors before the first cycle and after the first cycle were screened. Based on the predictive factors, four supervised machine learning algorithms were respectively considered to build the predictive models: logistic regression (LR), random forest (RF), extreme gradient boosting (XGBoost), and light gradient boosting machine (LGBM). The performances of the prediction models were evaluated by the area under the receiver operator characteristic curve (AUC), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy. RESULTS Totally, 851 women (45.83%) had a live birth. The LGBM model showed a robust performance in predicting live birth before the first cycle, with AUC being 0.678 [95% confidence interval (CI): 0.651 to 0.706] in the training set, 0.612 (95% CI: 0.553 to 0.670) in the validation set, 0.634 (95% CI: 0.511 to 0.758) in the testing set, and 0.670 (95% CI: 0.626 to 0.715) in the bootstrap validation. The AUC value in the training set, validation set, testing set, and bootstrap of LGBM to predict live birth after the first cycle was 0.841 (95% CI: 0.821 to 0.861), 0.816 (95% CI: 0.773 to 0.859), 0.835 (95% CI: 0.743 to 0.926), and 0.839 (95% CI: 0.806 to 0.871), respectively. CONCLUSION The LGBM model based on the predictive factors before and after the first cycle for live birth in women showed a good predictive performance. Therefore, it may assist fertility specialists and patients to adjust the appropriate treatment strategy.
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Affiliation(s)
- Xiaoyan Liu
- Reproductive Medicine Center, Huizhou Municipal Central Hospital, Huizhou, 516001, P.R. China
| | - Zhiyun Chen
- Reproductive Medicine Center, Huizhou Municipal Central Hospital, Huizhou, 516001, P.R. China
| | - Yanqin Ji
- Obstetrics and Gynecology, Huizhou Municipal Central Hospital, Xiapu Branch, No. 8 Hengjiang 4Th Road, Huizhou, 516001, P.R. China.
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Liu Y, Wu Y, Pan Z, Jiang F, Lu Y, Meng Y. Single-Dose Versus Multiple-Dose GnRH Agonist for Luteal-Phase Support in Women Undergoing IVF/ICSI Cycles: A Network Meta-Analysis of Randomized Controlled Trials. Front Endocrinol (Lausanne) 2022; 13:802688. [PMID: 35432219 PMCID: PMC9008129 DOI: 10.3389/fendo.2022.802688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 03/02/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Although gonadotropin-releasing hormone (GnRH) agonist has been introduced as a beneficial luteal phase support (LPS), the optimal strategy of GnRH agonist remains unclear. This network meta-analysis was therefore performed to determine the comparative efficacy and safety of multiple-dose versus single-dose GnRH agonist protocol for LPS in patients undergoing IVF/ICSI cycles. METHODS We searched relevant studies in PubMed, Embase and the Cochrane Registry of Controlled Trials (CENTRAL) from their inception util to September 2021. Live birth, clinical pregnancy rate, multiple pregnancy rate, and clinical abortion rate was evaluated. Pairwise and network meta-analysis were conducted using RevMan and ADDIS based on random-effects model, respectively. Moreover, the prioritization of protocols based on ranking probabilities for different outcomes were performed. RESULTS Sixteen RCTs met our eligibility criteria. Pairwise meta-analysis showed that multiple-dose protocol of GnRH agonist was effective for increasing live birth rate (OR 1.80, 95% CI 1.15 to 2.83, p=0.01) and clinical pregnancy rate (OR 1.89, 95% CI 1.01 to 3.56, p=0.05) as well as decreasing clinical abortion rate (OR 0.55, 95% CI 0.34 to 0.90, p=0.02). Meanwhile, single-dose protocol of GnRH agonist was effective for increasing clinical pregnancy rate (OR 1.45, 95% CI 1.11 to 1.89, p=0.007) and multiple pregnancy rate (OR 2.55, 95% CI 1.12 to 5.78, p=0.03). However, network meta-analysis only confirmed that multiple-dose protocol of GnRH agonist was the best efficacious strategy for live birth rate (OR 2.04, 95% CrI 1.19 to 3.93) and clinical pregnancy rate (OR 2.10, 95% CrI 1.26 to 3.54). CONCLUSION Based on the results of NMA, multiple-dose protocol may be the optimal strategy for patients undergoing IVF/ICSI cycles owing to its advantage in increasing live birth and clinical pregnancy rate. Moreover, single-dose protocol may be the optimal strategy for improving multiple pregnancy rate. However, with the limitations, more RCTs are required to confirm our findings.
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Affiliation(s)
| | | | | | | | - Youhui Lu
- *Correspondence: Yushi Meng, ; Youhui Lu,
| | - Yushi Meng
- *Correspondence: Yushi Meng, ; Youhui Lu,
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Zareii A, Davoodi S, Alborzi M, Moghadam ME, Askary E. Co-administration of GnRH agonists with vaginal progesterone compared to vaginal progesterone in luteal phase support of the frozen-thawed embryo transfer cycle: An RCT. Int J Reprod Biomed 2021; 19:863-872. [PMID: 34805726 PMCID: PMC8595909 DOI: 10.18502/ijrm.v19i10.9817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 09/01/2020] [Accepted: 11/24/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Since progesterone alone does not seem to be enough for luteal phase support (LPS), especially in frozen embryo transfer (FET) cycles, so gonadotropin-releasing hormone agonist (GnRH-a) is suggested as an adjuvant therapy in combination with progesterone for LPS. OBJECTIVE To evaluate the effects of the administration of GnRH-a with vaginal progesterone compared to vaginal progesterone alone in luteal phase support of the frozen-thawed embryo transfer cycles. MATERIALS AND METHODS In this randomized controlled clinical trial, 240 infertile women who were candidates for FET were evaluated into two groups (n = 120/each). Group I received 400 mg vaginal progesterone twice a day from the time of transfer. The second group received vaginal progesterone and also 0.1 mg diphereline on days 0, 3, and 6 of FET for LPS. Finally, the clinical and ongoing pregnancy rates, and the implantation, and spontaneous abortion rates were compared in two groups. RESULTS Results showed that there was no significant difference between the mean age of women and the duration of infertility (p = 0.78, p = 0.58, respectively). There were no significant differences between groups in the terms of implantation and spontaneous abortion rates (p = 0.19, p = 0.31, respectively). However, in terms of clinical and ongoing pregnancy rates, the significant differences were seen between groups (p = 0.008 and p = 0.005, respectively). CONCLUSION Co-administration of GnRH-a and vaginal progesterone in LPS may be superior to vaginal progesterone alone in women who underwent a frozen-selected embryo transfer cycle.
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Affiliation(s)
- Afsoon Zareii
- Infertility Division, Infertility Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sara Davoodi
- Infertility Division, Infertility Research Center, Department of Obstetrics and Gynecology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahshid Alborzi
- Infertility Division, School of Medicine, Jahrom University of Medical Sciences, Jahrom, Iran
| | | | - Elham Askary
- Department of Obstetrics and Gynecology, Laparoscopy Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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Saharkhiz N, Salehpour S, Hosseini S, Hosseinirad H, Nazari L. Effects of gonadotropin-releasing hormone agonist (GnRH-a) as luteal phase support in intracytoplasmic sperm injection (ICSI) cycles: a randomized controlled trial. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2020. [DOI: 10.1186/s43043-020-00030-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
This paper describes a blind randomized controlled trial (RCT) designed to evaluate the effect of gonadotropin-releasing hormone agonist (GnRH-a) administration on outcomes of intracytoplasmic sperm injection (ICSI) in subjects stimulated with the gonadotropin-releasing hormone (GnRH) antagonist protocol. A total of 268 women who underwent ICSI cycles with GnRH antagonist ovarian stimulation protocol were included in the study. Patients were randomly assigned to the intervention (GnRH-a) and control groups. The intervention group received a single dose injection of triptorelin (0.1 mg) subcutaneously 6 days after oocyte retrieval while the control group received placebo. The rates of chemical and clinical pregnancy were defined as the primary outcome values.
Results
Two hundred forty participants accomplished the study, and their data were analyzed. No significant difference was detected between the chemical pregnancy rates of the intervention and control groups. However, the clinical pregnancy rate was significantly higher in the GnRH-a group than in the placebo group.
Conclusions
The findings of the present study suggest that the GnRH-a support in the luteal phase can result in a significant improvement of pregnancy rates in ICSI cycles following the ovarian stimulation with GnRH antagonist protocol.
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Chau LTM, Tu DK, Lehert P, Dung DV, Thanh LQ, Tuan VM. Clinical pregnancy following GnRH agonist administration in the luteal phase of fresh or frozen assisted reproductive technology (ART) cycles: Systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol X 2019; 3:100046. [PMID: 31403130 PMCID: PMC6687475 DOI: 10.1016/j.eurox.2019.100046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 04/25/2019] [Accepted: 05/10/2019] [Indexed: 11/19/2022] Open
Abstract
Objective(s) To study if the GnRH agonist administration in luteal phase improves clinical pregnancy rate of fresh and frozen embryo transfer. Also, this meta-analysis compares the treatment effect of luteal GnRH agonist administration between long agonist and antagonist protocols of fresh cycles, and between two types of treatment: fresh and frozen embryo transfers. Study design Systematic review and meta-analysis (registration number CRD42017059152) Results For the overall 20 studies (5497 patients), clinical pregnancy rate significantly increased in group of GnRH agonist administration compared to control group (RR 1.24, 95% CI 1.14–1.34, p < 0.0001). Regarding the treatment effect of luteal GnRH agonist administration between long agonist and antagonist protocol fresh cycles, no significant difference was observed (RR = 1.28, 95% CI 0.98–1.67, p = 0.07). Also, in comparison between fresh and frozen embryo transfer, similar effect of GnRH agonist administration was found (RR = 0.93, 95% CI 0.74–1.16, p = 0.49). Conclusion(s) There is evidence that GnRH agonist administration in luteal phase improve clinical pregnancy rate in both fresh and frozen cycles. Within fresh cycles, no significant difference of clinical pregnancy rate is found between two protocols. In frozen cycles, the effect of GnRH agonist administration in enhancing clinical pregnancy rate is similar to fresh cycles.
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Affiliation(s)
- Le Thi Minh Chau
- Department of Infertility, Tu Du hospital, Vietnam
- Corresponding author at: Tu Du hospital.
| | | | - Philippe Lehert
- Faculty of Medicine, the University of Melbourne, Australia
- Faculty of Economics, UCL Mons, Louvain, Belgium
| | - Do Van Dung
- University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
| | | | - Vo Minh Tuan
- University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
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Li S, Li Y. Administration of a GnRH agonist during the luteal phase frozen-thawed embryo transfer cycles: a meta-analysis. Gynecol Endocrinol 2018; 34:920-924. [PMID: 29996682 DOI: 10.1080/09513590.2018.1480714] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
At present, the precise role of GnRH agonists during the luteal phase remains uncertain. In the present study, a meta-analysis was used to evaluate the effect of administering a GnRH agonist to during the luteal phase in patients undergoing FET cycles. A literature review was carried out by searching the current content of MEDLINE, Embase, the Cochrane Controlled Trials Register and Ovid. We particularly focused upon implantation rate, CPR per transfer, and ongoing pregnancy rate. All of the trials analyzed involved a GnRH agonist administered during the luteal phase. Six trials involving 1137 women were included in our meta-analysis. All of the cycles analyzed exhibited significantly higher implantation rates, clinical pregnancy rates, and ongoing pregnancy rates in the group of patients administered with a GnRH agonist during the luteal phase compared with the control group that did not receive a GnRH agonist during the luteal phase. Our data, therefore, demonstrate that the administration of a GnRH agonist during the luteal phase can significantly increase clinical pregnancy and ongoing pregnancy rates in FET cycles. The implantation rates, clinical pregnancy rates, and ongoing pregnancy rates can significantly increase in the group of patients administered with a GnRH agonist in natural cycle FET.
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Affiliation(s)
- Shuyi Li
- a Department of Reproductive Medicine, Xiangya Hospital , Central South University , Changsha , Hunan , PR China
| | - Yanping Li
- a Department of Reproductive Medicine, Xiangya Hospital , Central South University , Changsha , Hunan , PR China
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Mid-luteal phase gonadotropin-releasing hormone agonist support in frozen-thawed embryo transfers during artificial cycles: A prospective interventional pilot study. J Gynecol Obstet Hum Reprod 2018; 47:391-395. [PMID: 29684629 DOI: 10.1016/j.jogoh.2018.04.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 04/15/2018] [Accepted: 04/17/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess the effect of an additional single mid-luteal dose of gonadotropin-releasing hormone agonist (GnRHa) on pregnancy and perinatal outcomes in hormonally substituted frozen embryo transfer (FET) cycles. STUDY DESIGN A prospective interventional pilot study. Women scheduled for FET were randomly selected to receive standard hormonal replacement therapy (HRT) for endometrial preparation or HRT with a single additional subcutaneous dose of 0.1mg triptorelin at the time of implantation. If FET was not followed by a pregnancy, women with surplus embryos were scheduled for a single second attempt in a crossover setting. Altogether, 144 FET cycles were analyzed. The carryover effect was tested using a logistic regression model. Logistic regression analysis for binary variables was applied with generalized estimation equation extension to account for dependence among repeated treatments. RESULTS The live birth rate (LBR) was 9.8 percentage points higher and the miscarriage rate 14.7 percentage points lower in the intervention group (n=72) than in the control group (n=72), but the differences did not reach statistical significance. Implantation and clinical pregnancy rates were comparable between the groups. No congenital malformations or differences in the median birth weight of newborns were detected. CONCLUSIONS Observable but statistically insignificant difference in LBR and miscarriage rate favoring luteal phase GnRHa support was detected. Further, no malformations or effect on fetal growth were observed. Larger studies are needed to confirm the results of this pilot study.
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Benmachiche A, Benbouhedja S, Zoghmar A, Boularak A, Humaidan P. Impact of Mid-Luteal Phase GnRH Agonist Administration on Reproductive Outcomes in GnRH Agonist-Triggered Cycles: A Randomized Controlled Trial. Front Endocrinol (Lausanne) 2017; 8:124. [PMID: 28663739 DOI: 10.3389/fendo.2017.00124/bibtex] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 05/22/2017] [Indexed: 05/28/2023] Open
Abstract
OBJECTIVE To explore whether the addition of a mid-luteal bolus of GnRH agonist (GnRHa) improves the implantation rate (IR) in in vitro fertilization (IVF) cycles. DESIGN A randomized controlled trial. SETTING Private IVF center. PATIENTS 328 IVF/intracytoplasmic sperm injection patients were triggered with GnRHa and received 1,500 IU HCG on the day of oocyte pick-up (OPU) in addition to a standard luteal phase support (LPS). INTERVENTIONS In addition, the study group received a bolus of GnRHa 6 days after OPU, whereas the control group did not. MAIN OUTCOME MEASURE Implantation rate. SECONDARY OUTCOME MEASURES Ongoing pregnancy (OP) and live birth (LB) rates. RESULTS Although serum concentrations of FSH, LH, E2, and P on day OPU + 7 were significantly higher in the study group compared to the control group, the IR was not statistically different between the treatment group (27%) and the control group (23%) [odds ratio (OR) 1.2 (95% CI 0.9-1.7), P < 0.27]. Similarly, the OP rate was 37% in the treatment group and 31% in the control group [OR 1.3 (95% CI 0.8-2.0), P < 0.23]. The LB rate was 36% in the treatment group and 31% in the control group [OR: 1.3 (95% CI 0.8-2.0), P < 0.27]. CONCLUSION Although a trend toward a higher IR and pregnancy rate was observed in the treatment group, this difference was not statistically significant. However, the absolute risk difference of 5% found for LB is clinically relevant, warranting further investigation. NCT 02053779.
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Affiliation(s)
| | - Sebti Benbouhedja
- Center for Reproductive Medicine, Clinique Ibn Rochd, Constantine, Algeria
| | - Abdelali Zoghmar
- Center for Reproductive Medicine, Clinique Ibn Rochd, Constantine, Algeria
| | - Amel Boularak
- Center for Reproductive Medicine, Clinique Ibn Rochd, Constantine, Algeria
| | - Peter Humaidan
- The Fertility Clinic, Skive Regional Hospital, Skive, Denmark
- Faculty of Health Aarhus University, Aarhus, Denmark
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Benmachiche A, Benbouhedja S, Zoghmar A, Boularak A, Humaidan P. Impact of Mid-Luteal Phase GnRH Agonist Administration on Reproductive Outcomes in GnRH Agonist-Triggered Cycles: A Randomized Controlled Trial. Front Endocrinol (Lausanne) 2017; 8:124. [PMID: 28663739 PMCID: PMC5471294 DOI: 10.3389/fendo.2017.00124] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 05/22/2017] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To explore whether the addition of a mid-luteal bolus of GnRH agonist (GnRHa) improves the implantation rate (IR) in in vitro fertilization (IVF) cycles. DESIGN A randomized controlled trial. SETTING Private IVF center. PATIENTS 328 IVF/intracytoplasmic sperm injection patients were triggered with GnRHa and received 1,500 IU HCG on the day of oocyte pick-up (OPU) in addition to a standard luteal phase support (LPS). INTERVENTIONS In addition, the study group received a bolus of GnRHa 6 days after OPU, whereas the control group did not. MAIN OUTCOME MEASURE Implantation rate. SECONDARY OUTCOME MEASURES Ongoing pregnancy (OP) and live birth (LB) rates. RESULTS Although serum concentrations of FSH, LH, E2, and P on day OPU + 7 were significantly higher in the study group compared to the control group, the IR was not statistically different between the treatment group (27%) and the control group (23%) [odds ratio (OR) 1.2 (95% CI 0.9-1.7), P < 0.27]. Similarly, the OP rate was 37% in the treatment group and 31% in the control group [OR 1.3 (95% CI 0.8-2.0), P < 0.23]. The LB rate was 36% in the treatment group and 31% in the control group [OR: 1.3 (95% CI 0.8-2.0), P < 0.27]. CONCLUSION Although a trend toward a higher IR and pregnancy rate was observed in the treatment group, this difference was not statistically significant. However, the absolute risk difference of 5% found for LB is clinically relevant, warranting further investigation. NCT 02053779.
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Affiliation(s)
- Abdelhamid Benmachiche
- Center for Reproductive Medicine, Clinique Ibn Rochd, Constantine, Algeria
- *Correspondence: Abdelhamid Benmachiche,
| | - Sebti Benbouhedja
- Center for Reproductive Medicine, Clinique Ibn Rochd, Constantine, Algeria
| | - Abdelali Zoghmar
- Center for Reproductive Medicine, Clinique Ibn Rochd, Constantine, Algeria
| | - Amel Boularak
- Center for Reproductive Medicine, Clinique Ibn Rochd, Constantine, Algeria
| | - Peter Humaidan
- The Fertility Clinic, Skive Regional Hospital, Skive, Denmark
- Faculty of Health Aarhus University, Aarhus, Denmark
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Martins WP, Ferriani RA, Navarro PA, Nastri CO. GnRH agonist during luteal phase in women undergoing assisted reproductive techniques: systematic review and meta-analysis of randomized controlled trials. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:144-151. [PMID: 25854891 DOI: 10.1002/uog.14874] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 03/27/2015] [Accepted: 04/05/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To identify, evaluate and summarize the available evidence regarding the effectiveness and safety of administering a gonadotropin releasing hormone (GnRH) agonist during the luteal phase in women undergoing assisted reproductive techniques. METHODS In this systematic review and meta-analysis, we searched for randomized controlled trials (RCTs) comparing the addition of a GnRH agonist during the luteal phase, compared with standard luteal-phase support. We searched seven electronic databases and hand-searched the reference lists of included studies and related reviews. Our primary outcome was live birth or ongoing pregnancy per randomized woman. Our secondary outcomes were clinical pregnancy per randomized woman, miscarriage per clinical pregnancy, adverse perinatal outcome and congenital malformations. RESULTS The evidence from eight studies examining 2776 women showed a relative risk (RR) for live birth or ongoing pregnancy of 1.26 (95% CI, 1.04-1.53; I(2) = 58%). Sensitivity analysis when excluding the studies that did not report live birth and those at high risk of bias resulted in one study examining 181 women with an RR of 1.07 (95% CI, 0.73-1.58). Subgroup analysis separating the studies by single/multiple doses of GnRH agonists or by ovarian stimulation with GnRH agonist/antagonist was unable to explain the observed heterogeneity. The quality of the evidence was deemed to be very low: it was downgraded because of the limitation of the included studies, imprecision, inconsistency across the studies' results, and suspicion of publication bias. None of the included studies reported adverse perinatal outcomes or congenital malformations. CONCLUSIONS There is evidence that adding GnRH agonist during the luteal phase improves the likelihood of ongoing pregnancy. However, this evidence is of very low quality and there is no evidence for adverse perinatal outcome and congenital malformations. We therefore believe that including this intervention in clinical practice would be premature.
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Affiliation(s)
- W P Martins
- Department of Obstetrics and Gynecology, Ribeirao Preto Medical School, University of Sao Paulo (DGO-FMRP-USP), Ribeirao Preto, Brazil
| | - R A Ferriani
- Department of Obstetrics and Gynecology, Ribeirao Preto Medical School, University of Sao Paulo (DGO-FMRP-USP), Ribeirao Preto, Brazil
| | - P A Navarro
- Department of Obstetrics and Gynecology, Ribeirao Preto Medical School, University of Sao Paulo (DGO-FMRP-USP), Ribeirao Preto, Brazil
| | - C O Nastri
- Department of Obstetrics and Gynecology, Ribeirao Preto Medical School, University of Sao Paulo (DGO-FMRP-USP), Ribeirao Preto, Brazil
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Davar R, Farid Mojtahedi M, Miraj S. Effects of single dose GnRH agonist as luteal support on pregnancy outcome in frozen-thawed embryo transfer cycles: an RCT. IRANIAN JOURNAL OF REPRODUCTIVE MEDICINE 2015; 13:483-8. [PMID: 26568750 PMCID: PMC4637112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is no doubt that luteal phase support is essential to enhance the reproductive outcome in IVF cycles. In addition to progesterone and human chorionic gonadotropin, several studies have described GnRH agonists as luteal phase support to improve implantation rate, pregnancy rate and live birth rate, whereas other studies showed dissimilar conclusions. All of these studies have been done in fresh IVF cycles. OBJECTIVE To determine whether an additional GnRH agonist administered at the time of implantation for luteal phase support in frozen-thawed embryo transfer (FET) improves the embryo developmental potential. MATERIALS AND METHODS This is a prospective controlled trial study in 200 FET cycles, patients were randomized on the day of embryo transfer into group 1 (n=100) to whom a single dose of GnRH agonist (0.1 mg triptorelin) was administered three days after transfer and group 2 (n=100), who did not receive agonist. Both groups received daily vaginal progesterone suppositories plus estradiol valerate 6 mg daily. Primary outcome measure was clinical pregnancy rate. Secondary outcome measures were implantation rate, chemical, ongoing pregnancy rate and abortion rate. RESULTS A total of 200 FET cycles were analyzed. Demographic data and embryo quality were comparable between two groups. No statistically significant difference in clinical and ongoing pregnancy rates was observed between the two groups (26% versus 21%, p=0.40 and 21% versus 17%, p=0.37, respectively). CONCLUSION Administration of a subcutaneous GnRH agonist at the time of implantation does not increase clinical or ongoing pregnancy.
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van der Linden M, Buckingham K, Farquhar C, Kremer JAM, Metwally M. Luteal phase support for assisted reproduction cycles. Cochrane Database Syst Rev 2015; 2015:CD009154. [PMID: 26148507 PMCID: PMC6461197 DOI: 10.1002/14651858.cd009154.pub3] [Citation(s) in RCA: 130] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Progesterone prepares the endometrium for pregnancy by stimulating proliferation in response to human chorionic gonadotropin(hCG) produced by the corpus luteum. This occurs in the luteal phase of the menstrual cycle. In assisted reproduction techniques(ART), progesterone and/or hCG levels are low, so the luteal phase is supported with progesterone, hCG or gonadotropin-releasing hormone (GnRH) agonists to improve implantation and pregnancy rates. OBJECTIVES To determine the relative effectiveness and safety of methods of luteal phase support provided to subfertile women undergoing assisted reproduction. SEARCH METHODS We searched databases including the Cochrane Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO and trial registers. We conducted searches in November 2014, and further searches on 4 August 2015. SELECTION CRITERIA Randomised controlled trials (RCTs) of luteal phase support using progesterone, hCG or GnRH agonist supplementation in ART cycles. DATA COLLECTION AND ANALYSIS Three review authors independently selected trials, extracted data and assessed risk of bias. We calculated odds ratios (ORs) and 95%confidence intervals (CIs) for each comparison and combined data when appropriate using a fixed-effect model. Our primary out come was live birth or ongoing pregnancy. The overall quality of the evidence was assessed using GRADE methods. MAIN RESULTS Ninety-four women RCTs (26,198 women) were included. Most studies had unclear or high risk of bias in most domains. The main limitations in the evidence were poor reporting of study methods and imprecision due to small sample sizes.1. hCG vs placebo/no treatment (five RCTs, 746 women)There was no evidence of differences between groups in live birth or ongoing pregnancy (OR 1.67, 95% CI 0.90 to 3.12, three RCTs,527 women, I2 = 24%, very low-quality evidence, but I2 of 61% was found for the subgroup of ongoing pregnancy) with a random effects model. hCG increased the risk of ovarian hyperstimulation syndrome (OHSS) (1 RCT, OR 4.28, 95% CI 1.91 to 9.6, low quality evidence).2. Progesterone vs placebo/no treatment (eight RCTs, 875 women)Evidence suggests a higher rate of live birth or ongoing pregnancy in the progesterone group (OR 1.77, 95% CI 1.09 to 2.86, five RCTs, 642 women, I2 = 35%, very low-quality evidence). OHSS was not reported.3. Progesterone vs hCG regimens (16 RCTs, 2162 women)hCG regimens included comparisons of progesterone versus hCG and progesterone versus progesterone + hCG. No evidence showed differences between groups in live birth or ongoing pregnancy (OR 0.95, 95% CI 0.65 to 1.38, five RCTs, 833 women, I2 = 0%, low quality evidence) or in the risk of OHSS (four RCTs, 615 women, progesterone vs hCG OR 0.54, 95% CI 0.22 to 1.34; four RCTs,678 women; progesterone vs progesterone plus hCG, OR 0.34, 95% CI 0.09 to 1.26, low-quality evidence).4. Progesterone vs progesterone with oestrogen (16 RCTs, 2577 women)No evidence was found of differences between groups in live birth or ongoing pregnancy (OR 1.12, 95% CI 0.91 to 1.38, nine RCTs,1651 women, I2 = 0%, low-quality evidence) or OHSS (OR 0.56, 95% CI 0.2 to 1.63, two RCTs, 461 women, I2 = 0%, low-quality evidence).5. Progesterone vs progesterone + GnRH agonist (seven RCTs, 1708 women)Live birth or ongoing pregnancy rates were lower in the progesterone-only group and increased in women who received progester one and one or more GnRH agonist doses (OR 0.62, 95% CI 0.48 to 0.81, nine RCTs, 2861 women, I2 = 55%, random effects, low quality evidence). Statistical heterogeneity for this comparison was high because of unexplained variation in the effect size, but the direction of effect was consistent across studies. OHSS was reported in one study only (OR 1.00, 95% CI 0.33 to 3.01, 1 RCT, 300 women, very low quality evidence).6. Progesterone regimens (45 RCTs, 13,814 women)The included studies reported nine different comparisons between progesterone regimens. Findings for live birth or ongoing pregnancy were as follows: intramuscular (IM) versus oral: OR 0.71, 95% CI 0.14 to 3.66 (one RCT, 40 women, very low-quality evidence);IM versus vaginal/rectal: OR 1.24, 95% CI 1.03 to 1.5 (seven RCTs, 2309 women, I2 = 71%, very low-quality evidence); vaginal/rectal versus oral: OR 1.19, 95% CI 0.83 to 1.69 (four RCTs, 857 women, I2 = 32%, low-quality evidence); low-dose versus high-dose vaginal: OR 0.97, 95% CI 0.84 to 1.11 (five RCTs, 3720 women, I2 = 0%, moderate-quality evidence); short versus long protocol:OR 1.04, 95% CI 0.79 to 1.36 (five RCTs, 1205 women, I2 = 0%, low-quality evidence); micronised versus synthetic: OR 0.9, 95%CI 0.53 to 1.55 (two RCTs, 470 women, I2 = 0%, low-quality evidence); vaginal ring versus gel: OR 1.09, 95% CI 0.88 to 1.36 (oneRCT, 1271 women, low-quality evidence); subcutaneous versus vaginal gel: OR 0.92, 95% CI 0.74 to 1.14 (two RCTs, 1465 women,I2 = 0%, low-quality evidence); and vaginal versus rectal: OR 1.28, 95% CI 0.64 to 2.54 (one RCT, 147 women, very low-quality evidence). OHSS rates were reported for only two of these comparisons: IM versus oral, and low versus high-dose vaginal. No evidence showed a difference between groups.7. Progesterone and oestrogen regimens (two RCTs, 1195 women)The included studies compared two different oestrogen protocols. No evidence was found to suggest differences in live birth or ongoing pregnancy rates between a short and a long protocol (OR 1.08, 95% CI 0.81 to 1.43, one RCT, 910 women, low-quality evidence) or between a low dose and a high dose of oestrogen (OR 0.65, 95% CI 0.37 to 1.13, one RCT, 285 women, very low-quality evidence).Neither study reported OHSS. AUTHORS' CONCLUSIONS Both progesterone and hCG during the luteal phase are associated with higher rates of live birth or ongoing pregnancy than placebo.The addition of GnRHa to progesterone is associated with an improvement in pregnancy outcomes. OHSS rates are increased with hCG compared to placebo (only study only). The addition of oestrogen does not seem to improve outcomes. The route of progester one administration is not associated with an improvement in outcomes.
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Affiliation(s)
- Michelle van der Linden
- Radboud University Medical CenterDepartment of Obstetrics and GynaecologyPO Box 9101NijmegenNetherlands6500 HB
| | | | - Cindy Farquhar
- University of AucklandDepartment of Obstetrics and GynaecologyFMHS Park RoadGraftonAucklandNew Zealand1003
| | - Jan AM Kremer
- Radboud University Nijmegen Medical CenterDepartment of Obstetrics and GynaecologyPO Box 9101NijmegenNetherlands6500 HB
| | - Mostafa Metwally
- Sheffield Teaching HospitalsThe Jessop Wing and Royal Hallamshire HospitalSheffieldUKS10 2JF
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Pirard C, Loumaye E, Laurent P, Wyns C. Contribution to More Patient-Friendly ART Treatment: Efficacy of Continuous Low-Dose GnRH Agonist as the Only Luteal Support-Results of a Prospective, Randomized, Comparative Study. Int J Endocrinol 2015; 2015:727569. [PMID: 25945092 PMCID: PMC4402188 DOI: 10.1155/2015/727569] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 03/18/2015] [Indexed: 11/18/2022] Open
Abstract
Background. The aim of this pilot study was to evaluate intranasal buserelin for luteal phase support and compare its efficacy with standard vaginal progesterone in IVF/ICSI antagonist cycles. Methods. This is a prospective, randomized, open, parallel group study. Forty patients underwent ovarian hyperstimulation with human menopausal gonadotropin under pituitary inhibition with gonadotropin-releasing hormone antagonist, while ovulation trigger and luteal support were achieved using intranasal GnRH agonist (group A). Twenty patients had their cycle downregulated with buserelin and stimulated with hMG, while ovulation trigger was achieved using 10,000 IU human chorionic gonadotropin with luteal support by intravaginal progesterone (group B). Results. No difference was observed in estradiol levels. Progesterone levels on day 5 were significantly lower in group A. However, significantly higher levels of luteinizing hormone were observed in group A during the entire luteal phase. Pregnancy rates (31.4% versus 22.2%), implantation rates (22% versus 15.4%), and clinical pregnancy rates (25.7% versus 16.7%) were not statistically different between groups, although a trend towards higher rates was observed in group A. No luteal phase lasting less than 10 days was recorded in either group. Conclusion. Intranasal administration of buserelin is effective for providing luteal phase support in IVF/ICSI antagonist protocols.
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Affiliation(s)
- Céline Pirard
- Department of Gynecology-Andrology, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, 1200 Brussels, Belgium
| | | | - Pascale Laurent
- Department of Gynecology-Andrology, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, 1200 Brussels, Belgium
| | - Christine Wyns
- Department of Gynecology-Andrology, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, 1200 Brussels, Belgium
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Aboulghar MA, Marie H, Amin YM, Aboulghar MM, Nasr A, Serour GI, Mansour RT. GnRH agonist plus vaginal progesterone for luteal phase support in ICSI cycles: a randomized study. Reprod Biomed Online 2015; 30:52-6. [DOI: 10.1016/j.rbmo.2014.09.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 09/24/2014] [Accepted: 09/24/2014] [Indexed: 11/30/2022]
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Nawroth F. Additive hormonelle Therapie bei der assistierten Reproduktion. GYNAKOLOGISCHE ENDOKRINOLOGIE 2014. [DOI: 10.1007/s10304-013-0602-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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The addition of gonadotrophin releasing hormone agonist to routine luteal phase support in intracytoplasmic sperm injection and embryo transfer cycles: a randomized clinical trial. Eur J Obstet Gynecol Reprod Biol 2014; 182:66-70. [PMID: 25238659 DOI: 10.1016/j.ejogrb.2014.08.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Revised: 08/09/2014] [Accepted: 08/18/2014] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To determine the effects of addition of different dosages of gonadotrophin releasing hormone agonist (GnRH-a) to routine luteal phase support (LPS) on implantation and pregnancy rates. STUDY DESIGN Three hundred infertile couples who were treated by intracytoplasmic sperm injection and embryo transfer (ICSI-ET) following controlled ovarian stimulation (COS) with long luteal GnRH agonist protocol were enrolled. All women received 600 mg/day vaginal micronized progesterone plus 4 mg 17β estradiol for LPS starting from the day of oocyte retrieval. Patients (n=300) were randomized into three treatment groups. Group A (n=100) received leuprolide acetate 1 mg s.c. injection 3 days after ET in addition to routine LPS. Group B (n=100) received two sequential doses of leuprolide acetate 1 mg s.c. injections 3 and 6 days after ET in addition to routine LPS. Control group (n=100) received only the routine LPS. RESULTS A total of 279 patients completed the study. The groups were comparable in terms of baseline demographic parameters including age, duration of infertility and day 3 levels of FSH and estradiol. The cycle parameters of the groups were also comparable regarding the E2 level on day of hCG, number of retrieved oocytes, number of day 3 embryos, number of embryos transferred, and endometrial thickness on both days of OPU and ET. The implantation rates were similar in between the Groups A, B, and control group (20.7% and 25.8% vs. 13.3%, respectively; P=.099). The clinical pregnancy rates and miscarriage rates were similar in between the groups. The ongoing pregnancy rates were 27.4% in control group, 36% in Group A and 42.9% in Group B (P=.093). The OHSS rates were comparable in between the groups. The multiple pregnancy rates were significantly higher in Groups A and B than in control group (12% and 17.9% vs. 4.2%, respectively; P=.014). CONCLUSIONS The implantation, clinical pregnancy and ongoing pregnancy and multiple pregnancy rates seem to be increased with the addition of GnRH-a to routine luteal phase support.
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