What is the optimal GnRH antagonist protocol for ovarian stimulation during ART treatment? A systematic review and network meta-analysis

BACKGROUND

Several GnRH antagonist protocols are currently used during COS in the context of ART treatments; however, questions remain regarding whether these protocols are comparable in terms of efficacy and safety.

OBJECTIVE AND RATIONALE

A systematic review followed by a pairwise and network meta-analyses were performed. The systematic review and pairwise meta-analysis of direct comparative data according to the PRISMA guidelines evaluated the effectiveness of different GnRH antagonist protocols (fixed Day 5/6 versus flexible, ganirelix versus cetrorelix, with or without hormonal pretreatment) on the probability of live birth and ongoing pregnancy after COS during ART treatment. A frequentist network meta-analysis combining direct and indirect comparisons (using the long GnRH agonist protocol as the comparator) was also performed to enhance the precision of the estimates.

SEARCH METHODS

The systematic literature search was performed using Embase (Ovid), MEDLINE (Ovid), Cochrane Central Register of Trials (CENTRAL), SCOPUS and Web of Science (WOS), from inception until 23 November 2021. The search terms comprised three different MeSH terms that should be present in the identified studies: GnRH antagonist; assisted reproduction treatment; randomized controlled trial (RCT). Only studies published in English were included.

OUTCOMES

The search strategy resulted in 6738 individual publications, of which 102 were included in the systematic review (corresponding to 75 unique studies) and 73 were included in the meta-analysis. Most studies were of low quality. One study compared a flexible protocol with a fixed Day 5 protocol and the remaining RCTs with a fixed Day 6 protocol. There was a lack of data regarding live birth when comparing the flexible and fixed GnRH antagonist protocols or cetrorelix and ganirelix. No significant difference in live birth rate was observed between the different pretreatment regimens versus no pretreatment or between the different pretreatment protocols. A flexible GnRH antagonist protocol resulted in a significantly lower OPR compared with a fixed Day 5/6 protocol (relative risk (RR) 0.76, 95% CI 0.62 to 0.94, I2 = 0%; 6 RCTs; n = 907 participants; low certainty evidence). There were insufficient data for a comparison of cetrorelix and ganirelix for OPR. OCP pretreatment was associated with a lower OPR compared with no pretreatment intervention (RR 0.79, 95% CI 0.69 to 0.92; I2 = 0%; 5 RCTs, n = 1318 participants; low certainty evidence). Furthermore, in the network meta-analysis, a fixed protocol with OCP resulted in a significantly lower OPR than a fixed protocol with no pretreatment (RR 0.84, 95% CI 0.71 to 0.99; moderate quality evidence). The surface under the cumulative ranking (SUCRA) scores suggested that the fixed protocol with no pretreatment is the antagonist protocol most likely (84%) to result in the highest OPR. There was insufficient evidence of a difference between fixed/flexible or OCP pretreatment/no pretreatment interventions regarding other outcomes, such as ovarian hyperstimulation syndrome and miscarriage rates.

WIDER IMPLICATIONS

Available evidence, mostly of low quality and certainty, suggests that different antagonist protocols should not be considered as equivalent for clinical decision-making. More trials are required to assess the comparative effectiveness of ganirelix versus cetrorelix, the effect of different pretreatment interventions (e.g. progestins or oestradiol) or the effect of different criteria for initiation of the antagonist in the flexible protocol. Furthermore, more studies are required examining the optimal GnRH antagonist protocol in women with high or low response to ovarian stimulation.

Is analytical psychology a religion? Jung's search for a substitute for lost faith

Analytical psychology does not aim at curing neurotic symptoms, but at bringing about a change in the patient's attitude to him or her self, and therefore to life in general. This new attitude can be described as religious, but it has nothing to do with creeds or conventional forms of worship. Analytical psychology is not a religon, but can be described as a prolegomenon to religion or religion in statu nascendi.

Metal pyrazolate polymers. Part 1. Synthesis, structure, and magnetic properties of the [Cu(pz)2]x polymer

A novel and reliable method for the synthesis of polybis(μ-pyrazolato-N,N′)copper(II), [Cu(pz)2]x(where pz = N2C3H3), is presented. Single crystals of the polymer suitable for X-ray study have been grown under carefully controlled conditions. Crystals of polybis(μ-pyrazolato-N,N′)copper(II) are orthorhombic, a = 7.917(1), b = 11.491(2), c = 7.778(1) Å, Z = 4, space group Ibam. The structure was solved by direct methods and was refined by full-matrix least-squares procedures to R = 0.029 and Rw = 0.038 for 507 reflections with I ≥ 3σ(I). The crystal structure consists of infinite double-bridged polymeric chains. The Cu atom has a D2 distorted tetrahedral coordination geometry with Cu—N = 1.957(2) Å and N—Cu—N = 94.3(1)–139.5(1)°. Magnetic susceptibility studies (4.2 to 299 K) on this material reveal very strong antiferromagnetic exchange between copper(II) centres in the extended linear chains. The magnetic data have been successfully analyzed according to the isotropic Heisenberg model for linear chains with −J = 78 cm−1 and g = 2.12. Keywords: crystal structure, copper(II) pyrazolate chain polymer, antiferromagnetic exchange.

The 2-mercapto-1-methylimidazolyl moiety as a bridging ligand in complexes of gallium, rhenium, and molybdenum

The synthesis and characterization of complexes containing the 2-mercapto-1-methylimidazolyl ligand are described. [Formula: see text] occurs as a dimer, crystals of which are monoclinic, C2/c, a = 14.140(2), b = 7.4098(4), c = 18.024(2) Å, β = 106.38(1)°, Z = 4 dimers; the structure was determined by conventional heavy atom methods and refined by full-matrix least-squares techniques to a final R value of 0.039 for 1767 reflections. The crystal contains centrosymmetric dimeric molecules, with a central 8-membered ring, formed by mercaptoimidazolyl ligand bridging between dimethylgallium groups; galliumm has tetrahedral geometry, with no tendency to five-coordination, Ga—S = 2.3697(8), Ga—N = 2.019(2) Å. Reaction of [Formula: see text] L−, with [Re(CO)4Cl]2 results in the formation of LRe(CO)3, whose physical properties indicate a fac arrangement of the organogallate ligand. Attempts to synthesize corresponding LMo(η3-C4H7)(CO)2 and LMo(η3-C3H5)(CO)2 complexes yielded the dimeric species [Formula: see text] and [Formula: see text] Crystals of the [Formula: see text] complex are monoclinic, I2/a, a = 15.057(2), b = 9.4853(9), c = 18.240(2) Å, β = 108.67(1)°, Z = 4 dimers, R = 0.028 for 2363 reflexions. The structure contains dimeric molecules with C2 symmetry, and five fused rings, a central group of three 4-membered rings being formed by bonding of the S atoms of the ligands to both Mo atoms (in contrast to the gallium complex). The molecule has a U-shape, with Mo atoms having pseudo-octahedral environments, Mo—S = 2.6868(7), 2.5576(7), Mo—N = 2.253(2), Mo—CO = 1.950(2), Mo—C(allyl) = 2.259(3), 2.326(3) Å. Considerable strain in the chelate rings is indicated by angles as low as S—Mo—N = 63.9(1)°.

Isaac Newton

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A psychotherapist looks at depression

1. Depression is not an illness, but a psychobiological reaction which can be provoked in anyone.

2. It is much more easily provoked in some people than in others.

3. Vulnerability to depression is partly dependent upon social factors, as George Brown has demon strated. It is also determined by internal factors in the personality.

4. There is increasing evidence to show that the child's attachment to his mother is an important determinant of future mental health.

5. It will be argued that children who make ‘anxious attachments’ to the mother, as described by Bowlby, are less likely to incorporate her as a ‘good object’ within the psyche, and that this renders them more vulnerable to later depression than children who form ‘secuartetachments.’

6. Many features of depression in adults resemble or are related to ‘anxiouatstachments.’

7. The way in which psychotherapy can alleviate vulnerability to depression is described in terms of this hypothesis.

8. Reference is also made to the fact that effective action can be a source of self-esteem as well as love. Many of the great creators were partially effective in dealing with vulnerability to depression by work.

9. Freud affirmed that mental health depended upon the capacity to love and the capacity to work. It will be argued that the former capacity has been over-emphasized at the expense of the latter.

Safety, usefulness and acceptability of fibreoptic bronchoscopy in the elderly

The safety and usefulness of fibreoptic bronchoscopy in the elderly was assessed retrospectively in 204 consecutive patients aged 70 and over. One third of patients were examined as day cases. A bronchial tumour was seen in 67% patients, and biopsies showed malignancy in 78% of these cases. Certain knowledge of a diagnosis of bronchial carcinoma helped in the management of the elderly patient. Fibreoptic bronchoscopy proved to be safe in the presence of marked ventilatory impairment. A prospective questionnaire study in 114 patients showed that most patients found the procedure acceptable and would agree to a repeat if necessary and this was largely independent of age.

Gallium(III)-trisfluorosulfate

Gallium(III)-trisfluorosulfate is prepared by the reaction of gallium(III)-trichloride with either S2O6F2 or BrOSO2F. The i.r. spectrum is interpreted in terms of a polymeric compound containing bridging bidentate fluorosulfate groups only, thus resulting in hexacoordination around gallium. Gallium(III)–trisfluorosulfate is found to react with trimethylamine, however adducts of variable composition are formed.

Lewis Acid – Base Interactions Between Bis-π-cyclopentadienyl Tungsten and Molybdenum Dihydrides, Cp2MH2, and some Main Group III Moieties

Combination of the Lewis bases Cp2MH2 (where M = W or Mo) with the Group III Lewis acids AlR3 (where R = Me, Et, or Ph) and AlMe2H has yielded a series of 1:1 complexes of the type Cp2MH2•AlR3. A number of the complexes undergoes a slow elimination of hydrogen or alkane in benzene solution. Attempts to isolate mixed hydride adducts of the type, Cp2MH2•M′H3 (where M′ = Al or Ga), were unsuccessful.

Complexes of Group III trimethyls with diamines

Direct combination of the Lewis acids, Me3M (where M = B, Al, Ga, or In), and the diamines, Me2N(CH2)nNMe2 (where n = 1, 2, or 3) has given two series of complexes. A range of 1:1 complexes can be isolated with Me2NCH2NMe2 as ligand. With the other diamines, use of a 1:1 molar ratio of reactants yields crystalline 2:1 complexes with two moles of Me3M per mole of ligand. Excluding the reaction between Me3B and Me2NCH2NMe2, 2:1 complexes can be isolated by reacting the various Lewis acids with the appropriate molar quantity of the diamines. The complexes have been characterized by i.r. and proton n.m.r. spectroscopy and molecular weight measurements.A number of complexes of Me3Ga with methyl substituted ethylenediamines have been prepared and the effects of substitution on the nitrogen ligand atoms studied. Pyrolysis of these complexes has demonstrated the ready elimination of methane and has resulted in the formation of condensed Ga—N species.

Coordination compounds of methyl gallium hydrides

Although the organo hydride derivatives of boron and aluminium are well characterized, little work has been reported on the corresponding gallium systems. The present study was initiated to determine the relative stabilities of organo gallium hydride derivatives as compared to the stabilities of the corresponding compounds of boron and aluminium. Various preparative routes in this new class of gallium compounds have been investigated. These include the use of organo mercury and organo lithium reagents in reactions with gallium hydride compounds and their halogen substituted derivatives, and also equlibration reactions between gallium hydride and organo gallium compounds. Both infrared and proton magnetic resonance spectroscopy techniques have been used extensively in following the progress of these reactions and in the characterization of the products.