Differential impact of controlled ovarian hyperstimulation on live birth rate in fresh versus frozen embryo transfer cycles: a Society for Assisted Reproductive Technology Clinic Outcome System study

OBJECTIVE

To study the impact of both controlled ovarian hyperstimulation (COH) length and total gonadotropin (GN) dose individually and in concert on live birth rates (LBR) in both fresh and freeze-all in vitro fertilization embryo transfer (IVF-ET) cycles.

DESIGN

Historical cohort study.

SETTING

Not applicable.

PATIENT(S)

The U.S. national database from the Society of Assisted Reproductive Technology Clinic Outcome Reporting System from 2014 to 2015 was used to identify patients undergoing autologous GN stimulation IVF cycles with the use of GnRH antagonist-based suppression protocols where a single embryo transfer was performed as part of a fresh IVF-ET cycle (fresh, n = 14,866) or the first frozen embryo transfer after a freeze-all cycle (frozen, n = 2,964), and not including preimplantation genetic testing cycles. The patients' demographic and cycle characteristics, duration of COH, total GN dose, and pregnancy outcomes were extracted. Binomial regression models estimated trend and relative risk of live birth with respect to days of stimulation and total GN dose singularly, and after adjustment for a priori confounders including age, parity, body mass index, diagnosis, and maximum follicle-stimulating hormone in both fresh and frozen embryo transfer cycles. Both days of stimulation and total GN dose were then added to the multivariate model to show whether they were independently associated with LBR.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Live birth rate.

RESULTS

In both fresh and frozen cycles, length of COH was significantly associated with total GN dose. On univariate analysis, LBR decreased significantly with increasing length of stimulation and increasing total GN dose in both fresh and frozen cycles. On multivariable analysis including both days of stimulation and total GN dose, days of stimulation was no longer significantly correlated with LBR, whereas total GN dose remained significantly correlated with LBR in fresh cycles only. When total GN doses ranging from <2,000 IU through 5,000 IU to >5,000 IU were compared, a significant improvement in live birth rate was noted with lower total GN doses. Specifically, GN doses <2,000 IU had a 27% higher rate of live birth compared with GN dose >5,000 IU. For GN dose groups up to 4,000 IU, the estimated effect on LBR was similar. There was a marginal improvement (13%) in LBR with GN doses of 4,000 IU to 5,000 IU compared with >5,000 IU. When the multivariate model was applied to the frozen cycles, neither total GN dose nor days of stimulation was significantly associated with LBR.

CONCLUSIONS

High total GN dose but not prolonged COH is associated with decreasing LBRs in fresh cycles, whereas neither factor significantly affects LBR in frozen cycles. Consideration should be given to minimizing the total GN dose when possible in fresh autologous cycles, either by decreasing the daily dose or by limiting the length of stimulation to improve LBRs. In freeze-all cycles, the use of higher GN doses does not seem to adversely affect the LBR of the first frozen embryo transfer. High total GN dose likely exerts a negative impact on the endometrium and/or oocyte/embryo unrelated to the length of stimulation. The differential effect of total GN dose on LBR in fresh and frozen cycles may imply a greater impact exerted on the endometrium rather than the oocyte.

EVALUATION OF THE RISK FACTORS OF CERVICAL INSUFFICIENCY IN WOMEN WITH INFERTILITY ASSOCIATED WITH ANOVULATION

Cervical insufficiency is a common problem in obstetrical care. There are not enough studies about its development in women with infertility. The aim of the article was to determine the risk factors of the development of cervical insufficiency in women with infertility associated with anovulation. The object of the study were 308 pregnant women (110 pregnant women with cervical insufficiency and without infertility, 92 pregnant women with infertility associated with anovulation and with cervical insufficiency, 76 pregnant women with infertility associated with anovulation and without cervical insufficiency, 30 pregnant women without cervical insufficiency and infertility (controls)). We analyzed the data of obstetrical anamnesis, gynecological diseases, extragenital pathology. In fertile women with cervical insufficiency the traumatic factor of the cervix (previous labors, gynecological procedures connected with cervical dilatation) was the main in the development of this pathology. While in the women with infertility associated with anovulation the forming of cervical insufficiency was associated with hormonal reasons (hyperandrogenism (OR=3.04, 95 % CI=1.15-8.05, p=0.03), diminished ovarian reserve (OR=6.00, 95 % CI=1.97-18.24, p=0.002), controlled ovarian stimulation with gonadotropin and clomiphene citrate use (OR=3.69, 95% CI=1.93-7.04, p<0.001), use of additional reproductive technology (OR=1.95, 95 % CI=1.05-3.63, p=0.03).

Early onset of cabergoline therapy for prophylaxis from ovarian hyperstimulation syndrome (OHSS): A potentially safer and more effective protocol

Vascular endothelial growth factor (VEGF) is the most important angiogenic mediator in ovarian hyperstimulation syndrome OHSS. Studies proved that cabergoline administration blocks the increase in vascular permeability via dephosphorylation of VEGF receptors and hence can be used as prophylactic agent against OHSS. This study aimed at evaluating the effectiveness of early administration of cabergoline in the prevention of OHSS in high risk cases prepared for ICSI. This case series study was conducted on 126 high risk patients prepared for ICSI using the fixed antagonist protocol. High risk patients were defined as having more than 20 follicles >12 mm in diameter, and/or E2 more than 3000 pg/ml when the size of the leading follicle is more than 15 mm. When the size of the leading follicle reached 15 mm, cabergoline was administered (0.5 mg/day) for 8 days. Patients were followed up clinically, ultrasonographically and hematologically. The final E2 was 6099.5 ± 2730 and the mean number of retrieved oocytes was 19.7 ± 7.8. The clinical pregnancy rate was 62/126 (49.2%). There were no significant changes (p > 0.05) comparing hematological parameters, renal function tests and liver function tests between the day of HCG and the day of blastocyst transfer. The incidence of severe OHSS in this group was 1/126 (0.9%), while moderate OHSS was 12 (9.5%) and there were no cases of critical OHSS. We concluded that early administration of cabergoline is a safe and potentially more effective approach for prophylaxis against OHSS in high risk cases.

Extension of the clomiphene citrate stair-step protocol to gonadotropin treatment in women with clomiphene resistant polycystic ovarian syndrome

Our objective was to evaluate the safety and efficacy of direct initiation of gonadotropin ovarian stimulation without prior withdrawal bleeding in anovulatory clomiphene citrate (CC) resistant polycystic ovarian syndrome (PCOS) patients. Eighteen PCOS patients underwent ovulation induction with CC using a stair-step regimen. Patients who failed to respond to the maximal dose of CC initiated gonadotropin stimulation without inducing withdrawal bleeding, using the chronic low dose regimen. The primary outcome measure was the time to ovulation from the beginning of CC treatment until the day of ovulatory trigger. This was compared with the time to ovulation calculated according to the traditional approach, which includes inducing progesterone withdrawal bleeding between each CC dose increment and before gonadotropin therapy. The time to ovulation in the study group was 67.0 ± 6.8 days. The estimated time to ovulation according to the traditional approach was approximately 110 days. The clinical pregnancy rate was 44% (8/18), and all pregnancies were singletons. One patient miscarried; hence the live birth rate was 38.9% (7/18). Direct initiation of gonadotropin therapy without prior induction of withdrawal bleeding in clomiphene resistant PCOS patients results in considerable reduction of the time to ovulation and is both safe and efficacious.

Efficacy and Safety of Continuous Subcutaneous Infusion of Recombinant Human Gonadotropins for Congenital Micropenis during Early Infancy

BACKGROUND

Early postnatal administration of gonadotropins to infants with congenital hypogonadotropic hypogonadism (CHH) can mimic minipuberty, thereby increasing penile growth. We assessed the effects of gonadotropin infusion on stretched penile length (SPL) and hormone levels in infants with congenital micropenis.

METHODS

Single-center study including 6 males with micropenis in case of isolated CHH (n = 4), panhypopituitarism (n = 1), and partial androgen insensitivity syndrome (PAIS; n = 1). Patients were evaluated at baseline, monthly and at the end of the study through a clinical examination (SPL, testicular position and size), serum hormone assays (testosterone, luteinizing hormone, follicle-stimulating hormone, inhibin B, anti-Müllerian hormone [AMH]), and ultrasound of penis/testes.

RESULTS

In CHH, significant increases occurred in serum testosterone (from undetectable level to 3.5 ± 4.06 ng/mL [12.15 ± 14.09 nmol/L]), SPL (from 13.8 ± 4.5 to 42.6 ± 5 mm; p < 0.0001), inhibin B (from 94.8 ± 74.9 to 469.4 ± 282.5 pg/mL, p = 0.04), and AMH (from 49.6 ± 30.6 to 142 ± 76.5 ng/mL, p = 0.03). Micropenis was corrected in all patients, except one. On treatment, in the patient with PAIS, SPL was increased from 13 to 38 mm.

CONCLUSIONS

Early gonadotropin infusion is a safe, well-tolerated and effective treatment. The effect in PAIS has not been reported previously. Long-term follow-up is needed to assess the impact, if any, on future fertility and reproduction.
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Risk of endometrial cancer in women treated with ovary-stimulating drugs for subfertility

BACKGROUND

Medical treatment for subfertility principally involves the use of ovary-stimulating agents, including selective oestrogen receptor modulators (SERMs), such as clomiphene citrate, gonadotropins, gonadotropin-releasing hormone (GnRH) agonists and antagonists, as well as human chorionic gonadotropin. Ovary-stimulating drugs may act directly or indirectly upon the endometrium (lining of the womb). Nulliparity and some causes of subfertility are recognized as risk factors for endometrial cancer.

OBJECTIVES

To evaluate the association between the use of ovary-stimulating drugs for the treatment of subfertility and the risk of endometrial cancer.

SEARCH METHODS

A search was performed in CENTRAL, MEDLINE (Ovid) and Embase (Ovid) databases up to July 2016, using a predefined search algorithm. A search in OpenGrey, ProQuest, ClinicalTrials.gov, ZETOC and reports of major conferences was also performed. We did not impose language and publication status restrictions.

SELECTION CRITERIA

Cohort and case-control studies reporting on the association between endometrial cancer and exposure to ovary-stimulating drugs for subfertility in adult women were deemed eligible.

DATA COLLECTION AND ANALYSIS

Study characteristics and findings were extracted by review authors independently working in pairs. Inconsistency between studies was quantified by estimating I2. Random-effects (RE) models were used to calculate pooled effect estimates. Separate analyses were performed, comparing treated subfertile women versus general population and/or unexposed subfertile women, to address the superimposition of subfertility as an independent risk factor for endometrial cancer.

MAIN RESULTS

Nineteen studies were eligible for inclusion (1,937,880 participants). Overall, the quality of evidence was very low, due to serious risk of bias and indirectness (non-randomised studies (NRS), which was reflected on the GRADE assessment.Six eligible studies, including subfertile women, without a general population control group, found that exposure to any ovary-stimulating drug was not associated with an increased risk of endometrial cancer (RR 0.96, 95% CI 0.67 to 1.37; 156,774 participants; very low quality evidence). Fifteen eligible studies, using a general population as the control group, found an increased risk after exposure to any ovary-stimulating drug (RR 1.75, 95% CI 1.18 to 2.61; 1,762,829 participants; very low quality evidence).Five eligible studies, confined to subfertile women (92,849 participants), reported on exposure to clomiphene citrate; the pooled studies indicated a positive association ( RR 1.32; 95% CI 1.01 to 1.71; 88,618 participants; very low quality evidence), although only at high dosage (RR 1.69, 95% CI 1.07 to 2.68; two studies; 12,073 participants) and at a high number of cycles (RR 1.69, 95% CI 1.16 to 2.47; three studies; 13,757 participants). Four studies found an increased risk of endometrial cancer in subfertile women who required clomiphene citrate compared to a general population control group (RR 1.87, 95% CI 1.00 to 3.48; four studies, 19,614 participants; very low quality evidence). These data do not tell us whether the association is due to the underlying conditions requiring clomiphene or the treatment itself.Using unexposed subfertile women as controls, exposure to gonadotropins was associated with an increased risk of endometrial cancer (RR 1.55, 95% CI 1.03 to 2.34; four studies; 17,769 participants; very low quality evidence). The respective analysis of two studies (1595 participants) versus the general population found no difference in risk (RR 2.12, 95% CI 0.79 to 5.64: very low quality evidence).Exposure to a combination of clomiphene citrate and gonadotropins, compared to unexposed subfertile women, produced no difference in risk of endometrial cancer (RR 1.18, 95% CI 0.57 to 2.44; two studies; 6345 participants; very low quality evidence). However, when compared to the general population, an increased risk was found , suggesting that the key factor might be subfertility, rather than treatment (RR 2.99, 95% CI 1.53 to 5.86; three studies; 7789 participants; very low quality evidence).

AUTHORS' CONCLUSIONS

The synthesis of the currently available evidence does not allow us to draw robust conclusions, due to the very low quality of evidence. It seems that exposure to clomiphene citrate as an ovary-stimulating drug in subfertile women is associated with increased risk of endometrial cancer, especially at doses greater than 2000 mg and high (more than 7) number of cycles. This may largely be due to underlying risk factors in women who need treatment with clomiphene citrate, such as polycystic ovary syndrome, rather than exposure to the drug itself. The evidence regarding exposure to gonadotropins was inconclusive.

GnRH antagonist rescue of a short-protocol IVF/ICSI cycle and GnRH agonist triggering to prevent ovarian hyperstimulation syndrome: two case reports

OBJECTIVE

To describe two clinical cases concerning patients at risk of developing severe ovarian hyperstimulation syndrome (OHSS) during in vitro fertilization (IVF) stimulation.

DESIGN

Description of clinical management and outcomes of patients using an IVF antagonist rescue protocol to prevent OHSS.

SETTING

Reproductive medicine unit, University Hospital.

MATERIALS AND METHODS

Two infertile patients undergoing controlled ovarian stimulation (COS) for IVF/intracytoplasmic sperm injection (ICSI) presenting with high risk of OHSS. IVF/ICSI patients following COS under short protocol and high risk of OHSS were managed by withdrawing the agonist and replacing it with an antagonist and triggering ovulation with an agonist bolus. Main outcome measures included incidence of OHSS, oocytes retrieved, and pregnancy rates.

RESULTS

None of the two patients developed OHSS. None of the patients had metaphase II retrieved oocytes at oocyte retrieval.

CONCLUSIONS

Use of COS with short protocol in an IVF/ICSI cycle carries a risk of severe OHSS. Rescuing the cycle by withdrawing the agonist and replacing it with an antagonist and triggering ovulation with an agonist bolus is not always effective and should not be used if short time interval between agonist replacement with antagonist and ovulation triggering is available.

An upper limit of gonadotropin dose in patients undergoing ART should be advocated

AIM

As no upper limit of the daily dose of gonadotropins (DD GN) used for controlled ovarian hyperstimulation (COH) in patients undergoing assisted reproductive technology (ART) has been established, we aimed to evaluate the efficacy of using different DD GN in terms of live-birth achievement.

METHODS

Data of patients treated at a single university medical center during the same period was analyzed retrospectively. Four groups were analyzed according to the DD GN administered: group I ("high dose"):  >225- ≤ 375 IU; Group II ("Very high dose"): 376-450 IU; group III ("extremely high dose"): 451-600 IU. Normo-responders treated with DD GN ≤250 IU served as control (C). Variables included were DD GN, total GN dose/cycle, age, FSH, BMI, gravidity, parity, cycle number, IVF/ICSI, infertility diagnosis treatment protocol and outcome parameters.

RESULTS

The analysis of 1394 treatment cycles of 943 patients indicated that DD and total dose of GN correlated negatively with the number of oocytes, implantation, clinical pregnancy and live-birth rate (25.9%, 14.6%, 11.4% and 4.7% in groups C, I, II and III, respectively) The logistic regression analysis indicated that the adjusted odds ratios for LBR correlated inversely with the DD administered - independently from age, baseline FSH, BMI and previous failed cycles.

CONCLUSIONS

Increasing the daily dose of GN to doses higher than 450 IU or a total dose of 3000 IU/cycle is at least questionable if not harmful.

Fertility preservation with ovarian stimulation protocols prior to cancer treatment

An increasing trend towards later childbearing has been reported recently in many developed countries. Although the incidence of reproductive age in women who have delayed pregnancy with cancer is 10%, they may be concerned regarding the preservation of ovarian function due to advanced fertile age and with the impact of cancer treatment on later fertility. Among multiple strategies controlled, ovarian stimulation for embryo or oocyte cryopreservation is currently the most established method for fertility preservation. It is important to choose the appropriate ovulation induction protocol prior to oncologic treatment, because most of these patients have only the chance of a single cycle to conceive. Current treatment protocols offer a minimal time delay until oncologic treatment is commenced. In urgent settings, random-start ovarian stimulation represents a new technique which provides a significant advantage by decreasing the total time of the treatment, because it may be started irrespective of the phase of the cycle without compromising oocyte yield and maturity before cancer treatment. However, in patients with oestrogen-sensitive cancers stimulation, protocols using letrozole are currently preferred over tamoxifen regimens, and therefore, it may be highly advisable to use letrozole with gonadotrophins routinely as a safe, effective and novel protocol of ovulation induction.

Fertility drug use and risk of ovarian tumors: a debated clinical challenge

Infertility itself increases the incidence of ovarian carcinoma, while the potential additional risk associated with the use of fertility drugs is still debated. In 1992, the cumulative analysis of 12 US case-control studies revealed that women who received ovulation-inducing drugs had approximately three-fold higher incidence of invasive ovarian carcinoma. Other investigations reported a lower increase of the risk of invasive carcinoma or borderline tumor of the ovary in women treated with these agents. Conversely, several other case-control or cohort studies failed to detect a significant correlation between fertility drug use and ovarian tumor risk in either parous or nulliparous women compared with untreated infertile women. Moreover neither the number of treatment cycles nor the type of drug used was associated with an increased risk in most studies. Incessant ovulation and excessive gonadotropin secretion have been long considered to play a major role in the development of ovarian carcinoma, and therefore fertility drugs, which raise the serum levels of gonadotropins and increase the chances of multiple ovulations, have been retained as a risk factor for this malignancy, However, the large majority of literature data as well as the new hypotheses on ovarian carcinogenesis appear to exclude a relevant impact of fertility drug use on the risk of ovarian tumors, and especially of high-grade invasive epithelial ovarian cancers.

Moderate ovarian stimulation does not increase the incidence of human embryo chromosomal abnormalities in in vitro fertilization cycles

CONTEXT

A high chromosomal abnormalities rate has been observed in human embryos derived from in vitro fertilization (IVF) treatments. The real incidence in natural cycles has been poorly studied, so whether this frequency may be induced by external factors, such as use of gonadotropins for ovarian stimulation, remains unknown.

DESIGN

We conducted a prospective cohort study in a University-affiliated private infertility clinic with a comparison between unstimulated and stimulated ovarian cycles in the same women. Preimplantation genetic screening by fluorescence in situ hybridization was performed in all viable d 3 embryos.

OBJECTIVE

The primary objective was to compare the incidence of embryo chromosomal abnormalities in an unstimulated cycle and in an ulterior moderate ovarian stimulated cycle. Secondary outcome measures were embryo quality, blastocyst rate of biopsied embryos, number of normal blastocysts per donor, type of chromosomal abnormalities, and clinical outcome.

RESULTS

One hundred eighty-five oocyte donors were initially recruited for the unstimulated cycle, and preimplantation genetic screening could be performed in 51 of them, showing 35.3% of embryo chromosomal abnormalities. Forty-six of them later completed a stimulated cycle. The sperm donor sample was the same for both cycles. The proportion of embryos displaying abnormalities in the unstimulated cycle was 34.8% (16 of 46), whereas it was 40.6% (123 of 303) in the stimulated cycle with risk difference=5.8 [95% confidence interval (CI)=-20.6-9.0], and relative risk=1.17 (95% CI=0.77-1.77) (P=0.45). When an intrasubject comparison was made, the abnormalities rate was 34.8% (95% CI=20.5-49.1) in the unstimulated cycle and 38.2% (95% CI=30.5-45.8) in the stimulated cycle [risk difference=3.4 (95% CI=-17.9-11.2); P=0.64]. No differences were observed for embryo quality and type of chromosomal abnormalities.

CONCLUSIONS

Moderate ovarian stimulation in young normo-ovulatory women does not significantly increase the embryo aneuploidies rate in in vitro fertilization-derived human embryos as compared with an unstimulated cycle. Whether these results can be extrapolated to infertile patients is still unknown.

Iatrogenic prion diseases in humans: an update

Although Creutzfeldt-Jakob disease (CJD) was first identified in 1920, prevention of transmission raised particular concern all over the world when a new variant of the disease was first described in 1996. There is good evidence of iatrogenic transmission of this new variant among human beings through blood, blood components, tissues and growth hormone. Furthermore, four cases of iatrogenic transmission of CJD through fertility treatment with human pituitary-derived gonadotrophins have been reported. It is important to distinguish the categories of infectivity and categories of risk, which require consideration not only of the level of infectivity of a given tissue or fluid, but also the amount of tissue/fluid to which a person is exposed, the duration of exposure and the route by which infection is transmitted. The potential presence and infectivity of prion proteins in human urinary gonadotrophin preparations is a matter of debate. Differences in the sensitivity of bioassay methods are of paramount importance when considering the infectivity of a tissue. Some new methods might detect small amounts of agent in some tissues currently thought to be free of infectivity. No cases of human prion disease due to the use of urinary gonadotrophins have been recognized to date. However, the detection of prions in the urine of experimental animals and in some urine-based preparations, and the young age of fertility drug recipients, require the application of the precautionary principle to urinary preparations.

Controlled ovarian hyperstimulation in women with polycystic ovarian syndrome with or without intrauterine insemination

OBJECTIVE

To evaluate the value of intrauterine insemination (IUI) in controlled ovarian hyperstimulation (COH) among couples with polycystic ovary syndrome (PCOS) and normal semen analysis.

DESIGN

Retrospective cohort study.

SETTING

University teaching center.

PATIENTS

PCOS couples with normal semen analysis that underwent COH with IUI or timed intercourse (TIC).

INTERVENTION

COH with clomiphene citrate, letrozole or gonadotropins with or without IUI.

MAIN OUTCOME MEASURES

Clinical pregnancy rates.

RESULTS

Of a total 265 cycles, 151 cycles were with IUI and 114 others with TIC. No significant difference was found in the overall pregnancy rates between the TIC group (17.5%) and the IUI group (16.6%). Analysis of pregnancy rates according to the type of COH treatments did not demonstrate the advantages of IUI over TIC.

CONCLUSION

Compared to timed intercourse, IUI does not increase the pregnancy rate in couples with PCOS and normal semen analysis treated with COH.

Gonadotropin therapy: a 20th century relic

Gonadotropin therapy has been a cornerstone of infertility therapy for half a century. From the very beginning, its use has been associated with a high rate of multiple births, particularly high order multiples, and ovarian hyperstimulation syndrome. Initially, success rates seemed acceptable when used for superovulation (SO)/IUI therapy. However, as data from RCTs have emerged, reported outcomes suggest that we question the use of injectible gonadotropins. This manuscript examines the studies that have challenged gonadotropin use for SO/IUI and other research that supports reduced doses of gonadotropins for IVF. We examine the challenges for its continued use for SO/IUI and for moving to lower doses worldwide for IVF. We propose a future that views gonadotropins as a relic of the twentieth century.

Comparison of treatment outcomes of infertile women by clomiphene citrate and letrozole with gonadotropins underwent intrauterine insemination

This study was designed to compare the effect of clomiphene and letrozole in ovulatory stimulation in infertile women under intrauterine insemination who referred to Mahdiyeh infertility clinic during 2008-2009. 106 infertile women were randomly divided into two equal groups. Patients were treated with 5 mg of letrozole daily (in letrozole group) or 100 mg of clomiphene citrate daily (in clomiphene group) for five days starting on day 3 of their menses. Dose and time of FSH was similar in the two groups. Number of follicles, endometrial thickness, Pregnancy rate and prevalence of complications were compared in the two groups. Mean (±SD) of age in letrozole and clomiphene groups was 26.3 ± 3.9 and 25.2 ± 4.9 respectively (P=0.186). Average number of follicles was 2.5 ± 1.65 in letrozole group and 2.36 ± 1.4 in clomiphene group (P=0.764). β-hCG was positive in 11 (20.8%) in letrozole and 12 (22.6%) in clomiphene groups (P=0.814). Pregnancy rate was 20.8% and 22.6% in letrozole and clomiphene group respectively (P=0.814). There was no difference in rate of abortion between groups. Endometrial thickness (ET) at the time of hCG administration in the letrozole (6.8 ± 1.5 mm) and in clomiphene (6.6 ± 1.2 mm) (P=0.615). But ET>7.4 mm was found in 2 cased (3.8%) in clomiphene group and 12 cases (%22.8) in letrozole groups (P=0.01). It appears that letrozole and clomiphene have similar outcome infertile women under intrauterine insemination and these drugs are good alternative for each others.

[Influence duration of the use of estrogens beyond the menses in estradiol IVF antagonist programming cycles]

OBJECTIVE

To evaluate by the birth rate the impact of the number of days of estrogens continued beyond the menses in a four days estradiol IVF antagonist programming cycles.

PATIENTS AND METHODS

Retrospective study from September 2004 to January 2009 among women of age ranging between 25 and 38 years. Four milligrams of provames is prescribed 3 to 5 days before the theorical menses and continued until the beginning day of stimulation, which is distributed equitably between Thursday and Sunday. The birth rate is evaluated according to the number of days of estrogen continued beyond the menses within a limit from 1 to 8.

RESULTS

No significant difference appears neither in the duration of stimulation, in the quantity of gonadotrophin, the oocytes pick up, nor in the rate of birth between the groups.

CONCLUSION

The programming by estrogens of the antagonist IVF cycles implies a variable number of days of estrogens continued beyond the menses, which does not seem to affect the birth rate.

Ovulation induction with gonadotropins causes increased sister chromatid exchanges

Gonadotropins are widely accepted agents for ovulation induction in infertile women. On the other hand, several authors discuss the possible effect of gonadotropins on the developmental mechanism of ovarian cancer. SCE is a method of genotoxicity investigation and it is an excellent parameter to monitor the DNA damage and repair. There are numbers of studies showing the relationship between endogenous or exogenous hormones and SCEs. The aim of this study was to investigate with SCE techniques the effects of long-term (6 months) use of gonadotropins on DNA as we couldn't find any other study on the effect of long term use. We found increased sister chromatid exchange rates in a study group as compared to a control group. This may be one of the causes of increased ovarian cancer risk in infertile population.

Acute kidney injury due to menstruation-related disseminated intravascular coagulation in an adenomyosis patient: a case report

The authors report a case of acute kidney injury (AKI) resulting from menstruation-related disseminated intravascular coagulation (DIC) in an adenomyosis patient. A 40-yr-old woman who had received gonadotropin for ovulation induction therapy presented with anuria and an elevated serum creatinine level. Her medical history showed primary infertility with diffuse adenomyosis. On admission, her pregnancy test was negative and her menstrual cycle had started 1 day previously. Laboratory data were consistent with DIC, and it was believed to be related to myometrial injury resulting from heavy intramyometrial menstrual flow. Gonadotropin is considered to play an important role in the development of fulminant DIC. This rare case suggests that physicians should be aware that gonadotropin may provoke fulminant DIC in women with adenomyosis.

What is the optimal therapy for young males with hypogonadotropic hypogonadism?

Hypogonadotropic hypogonadism (HH), consequent to congenital or acquired disorders of the hypothalamic-pituitary axis, presents as absent/delayed/arrested sexual maturation and infertility. Optimal management includes: (a) confirmation of the diagnosis and prognosis, (b) timing and choice of therapeutic intervention and (c) consideration of future fertility prospects. Therapy is usually initiated with testosterone to induce development of secondary sexual characteristics, taking the patient (often diagnosed late) through puberty. Monitoring of the impact of the condition on long-term health and psychosocial function is necessary. Treatment is likely to be life-long, requiring regular monitoring for its optimization and avoidance of adverse responses. Induction of spermatogenesis requires either pulsatile gonadotropin releasing hormone (GnRH) or gonadotropin administration. Gonadotropins can be self-administered subcutaneously and are not inferior to the more costly GnRH. 'Reversible genetic hypogonadotropic hypogonadism' is a recently described entity which has implications for the long-term management of patients with HH.

Efficacy and safety of long-acting GnRH agonists in in vitro fertilization and embryo transfer

The introduction of gonadotrophin-releasing hormone (GnRH) agonists combined with gonadotrophins is considered to be one of the most significant events in the development of in vitro fertilization and embryo transfer (IVF-ET) programmes. This article reviews the use of GnRH agonists in IVF-ET programmes and the efficacy and safety of long-acting GnRH agonists. The use of agonists results in higher clinical pregnancy rates, more supernumerary embryos for cryopreservation and allows convenient programming of oocyte recovery. There are different types of agonist and ovarian stimulation protocol available for clinical use. Recent meta-analysis of the Cochrane database has demonstrated the superiority of the long protocols over the short and ultra-short protocols for GnRH agonist use in IVF and GIFT. The depot injection offers increased clinical and patient compliance and improves efficacy of pituitary downregulation. However, compared with short-acting agonists, the depot preparations are associated with a longer period of stimulation and higher doses of gonadotrophins. To date, there is no evidence of an increased risk of pregnancy wastages or teratogenicity in human pregnancies exposed to long-acting agonists.

Use of fertility drugs and risk of uterine cancer: results from a large Danish population-based cohort study

Some epidemiologic studies have indicated that uterine cancer risk may be increased after use of fertility drugs. To further assess this association, the authors used data from a large cohort of 54,362 women diagnosed with infertility who were referred to Danish fertility clinics between 1965 and 1998. In a case-cohort study, rate ratios and 95% confidence intervals were used to assess the effects of 4 groups of fertility drugs on overall risk of uterine cancer after adjustment for potentially confounding factors. Through mid-2006, 83 uterine cancers were identified. Ever use of any fertility drug was not associated with uterine cancer risk (rate ratio (RR) = 1.10, 95% confidence interval (CI): 0.69, 1.76). However, ever use of gonadotropins (follicle-stimulating hormone and human menopausal gonadotropin) increased uterine cancer risk (RR = 2.21, 95% CI: 1.08, 4.50); the risk was primarily observed after 10 years of follow-up. Furthermore, uterine cancer risk increased with number of cycles of use for clomiphene (for > or =6 cycles, RR = 1.96, 95% CI: 1.03, 3.72) and human chorionic gonadotropin (for > or =6 cycles, RR = 2.18, 95% CI: 1.16, 4.08) but not for other gonadotropins. Use of gonadotropin-releasing hormone analogs was not associated with risk. Gonadotropins, and possibly clomiphene and human chorionic gonadotropin, may increase the risk of uterine cancer, with higher doses and longer follow-up leading to greater risk.

Pelvic pain after gonadotropin administration as a potential sign of endometriosis

We describe five patients who developed significant pelvic pain, requiring narcotics, during a controlled ovarian hyperstimulation cycle and who were surgically diagnosed with significant endometriosis. Severe pain, especially if it requires narcotics, is unusual for patients undergoing controlled ovarian hyperstimulation and may be an indicator of endometriosis.

Ovulation induction treatment and risk of borderline ovarian tumors

AIM

Research has suggested an association between the use of ovulation induction drugs and the risk of ovarian cancer. It has also been proposed that there may be pre-cancerous alterations in the ovary which themselves are the cause of infertility. The aim of the present study was to evaluate the relationship between the use of ovulation induction drugs and the appearance of borderline ovarian tumors.

MATERIAL AND METHODS

This was a case-control study in which the study group comprised 42 women with a borderline ovarian tumor and the control group comprised 257 women with benign ovarian pathology.

RESULTS

No differences were found between the borderline tumor and control groups (14.3% vs. 27.2%, respectively) in terms of infertility history. Nor were there any differences between the groups with respect to the type of drug used, whether clomiphene citrate (9.5% vs. 6.2%, respectively) or gonadotropins (7.1% vs. 10.1%, respectively). Analysis in terms of the number of cycles administered also failed to reveal any differences. The mean number of cycles with clomiphene citrate/gonadotropins was 2.50 +/- 1.00 and 3.00 +/- 2.64 in the borderline tumor group and 2.44 +/- 1.75 and 3.27 +/- 2.25 in the control group.

CONCLUSIONS

Our series produced no evidence that ovulation induction treatment predisposes women to the development of borderline ovarian tumors.

Safety of drugs used in assisted reproduction techniques

Infertility may affect one in six couples; however, the development of the assisted reproduction technique (ART) created the opportunity for a large proportion of the infertile population to bear children. Pharmacological agents are routinely used in ART, and new ones are introduced regularly, with the aim of retrieving multiple oocytes to increase the prospect of pregnancy. The combinations of drugs that are used have specific adverse effects, but it is mostly the combined action of more than one agent that causes the greatest concern. The matter is complicated by the suspicion that some techniques in ART, for example intracytoplasmic sperm injection for severe male infertility problems (including azoospermia), may also contribute to the increase in adverse effects, especially congenital malformation. Gonadotropin releasing hormone (GnRH) agonists are widely used in controlled ovarian hyperstimulation. It may give rise to a short period of estradiol withdrawal symptoms and it may also lead to luteal phase deficiency. Similarly GnRHa antagonists, which have been recently introduced to control ovarian hyperstimulation, can lead to luteal phase deficiency and may cause some local injection site reactions. The more pure form of gonadotropin leads to less local injection site reactions and their main adverse effects are associated with the consequences of multiple ovulations. It has been proposed that gonadotropins may be a factor in the increasing risk of ovarian cancer and possibly breast cancer, but this has not been substantiated. Prion infection is another potential hazard, although no cases have been reported. Ovarian hyperstimulation syndrome is a well recognised complication of controlled ovarian hyperstimulation in ART. It is usually a result of recruitment of a large number of ovarian follicles. Efforts to minimise the incidence of this syndrome and its severity are now well developed. Congenital malformations are another possible adverse effect of fertility drugs, but it is more probable that the increase in congenital abnormality that is reported in ART is because of the population studied, i.e. patients already at high risk of congenital malformation, rather than the fertility drugs used or the technique employed. High order multiple pregnancy and its sequela is a well established complication of controlled ovarian hyperstimulation. This could be a result of multiple ovulations or more than one embryo replacement. Reducing the number of embryos transferred can reduce this more serious adverse effect for expectant mothers and for children conceived from ART.

Simultaneous bilateral ovarian torsion in the follicular phase after gonadotropin stimulation

OBJECTIVE

To present and discuss the first report of follicular phase bilateral ovarian torsion following a cancelled IVF cycle.

DESIGN

Case report.

SETTING

University-based assisted reproductive technology program.

PATIENT(S)

A 41-year-old nulligravid patient on day 3 of her menses following a cancelled IVF cycle.

INTERVENTION(S)

Gonadotropin ovulation induction; laparoscopy with detorsion of left and right ovaries; aspiration of cysts.

RESULT(S)

Ovarian torsion resolved; follicular development in the following natural cycle.

CONCLUSION(S)

This is a unique case of simultaneous bilateral ovarian torsion following a cancelled IVF cycle and presenting in the ensuing follicular phase. Physicians should be aware of this unusual risk related to persistently enlarged ovaries in the cycle following gonadotropin stimulation. Furthermore, management of the infertility patient should be conservative and focused on ovarian preservation whenever feasible. Early surgical intervention can permit reperfusion and salvage of the affected adnexa.

Treatment for infertility and risk of invasive epithelial ovarian cancer--a case report

A 30-year-old women was admitted to the Institute of Gynecology and Obstetrics, Clinical Center of Serbia in April 2004 with the following diagnosis: adnexal mass soon after in vitro fertilization. Her history revealed salpingo-oophorectomy for mucinous cystadenofibroma of the left ovary eight years before and cystectomy of the right ovary three years before. At admission, the most remarkable findings were high temperature and elevated white blood cells with erythrocyte sedimentation rate. After the antibiotic treatment, laparatomy was performed and a multilocular right adnexal tumor was found. The right salpingo-oophorectomy was performed and pathological diagnosis was mucinous ovarian adenocarcinoma. Two weeks later, radical surgery was carried out and chemotherapy was applied. There is an urgent need for clear interpretation of the link between ovarian stimulation and ovarian cancer. An association between ovarian stimulation treatment and ovarian cancer has still not been completely proven.

Ovarian adenomyoma following gonadotrophin treatment for infertility

An ovarian adenomyoma developed in a 38-year-old infertile patient following treatment with exogenous gonadotrophins. Laparoscopic excision was performed. Histological examination showed thick muscular bundles resembling myometrium lined with endometrial glands and stroma. Gonadotrophins might be involved in the pathogenesis of extrauterine adenomyoma.

Development of severe ovarian hyperstimulation syndrome after inadvertent stimulation with a gonadotropin-releasing hormone agonist and human menopausal gonadotropin in a pre-existing early pregnancy

OBJECTIVE

To report a case of severe ovarian hyperstimulation syndrome (OHSS) after inadvertent GnRH long protocol/hMG stimulation in a pre-existing early pregnancy.

DESIGN

Case report.

SETTING

Private infertility clinic.

PATIENT(S)

A 28-year-old woman who conceived spontaneously following IVF and cryo-embryo transfer (cryo-ET).

INTERVENTION(S)

IVF/intracytoplasmic sperm injection (ICSI), cryo-ET, analgesia, and forced diuresis.

MAIN OUTCOME MEASURE(S)

Viable pregnancy.

RESULT(S)

Viable pregnancy with OHSS despite inadvertent administration of GnRH-agonist, stimulation with hMG, and ET in a pre-existing pregnancy.

CONCLUSION(S)

Observation of follicle development following stimulation during pregnancy with low quantity and poor quality oocytes combined with abnormal endometrium.

The role of aromatase inhibitors in ameliorating deleterious effects of ovarian stimulation on outcome of infertility treatment

Clinical utilization of ovulation stimulation to facilitate the ability of a couple to conceive has not only provided a valuable therapeutic approach, but has also yielded extensive information on the physiology of ovarian follicular recruitment, endometrial receptivity and early embryo competency. One of the consequences of the use of fertility enhancing agents for ovarian stimulation has been the creation of a hyperestrogenic state, which may influence each of these parameters. Use of aromatase inhibitors reduces hyperestrogenism inevitably attained during ovarian stimulation. In addition, the adjunct use of aromatase inhibitors during ovarian stimulation reduces amount of gonadotropins required for optimum stimulation. The unique approach of reducing hyperestrogenism, as well as lowering amount of gonadotropins without affecting the number of mature ovarian follicles is an exciting strategy that could result in improvement in the treatment outcome by ameliorating the deleterious effects of the ovarian stimulation on follicular development, endometrial receptivity, as well as oocyte and embryo quality.

Melanoma, thyroid, cervical, and colon cancer risk after use of fertility drugs

OBJECTIVE

This study was undertaken to evaluate melanoma, thyroid, colon, and cervical cancer risks after clomiphene or gonadotropins.

STUDY DESIGN

Retrospective cohort of 8422 women (155,527 women-years) evaluated for infertility (1965-1988). Through 1999, cancers were ascertained by questionnaire, cancer and death registries. Poisson regression estimated adjusted rate ratios (RRs).

RESULTS

Clomiphene use did not significantly increase risk of melanoma (RR=1.66; 95% CI, 0.9-3.1), thyroid (RR=1.42; 95% CI, 0.5-3.7), cervical (RR=1.61; 95% CI, 0.5-4.7), or colon cancer (RR=0.83; 95% CI, 0.4-1.9). We found no relationship between clomiphene dose or cycles of use and cancer risk at any site. Clomiphene use may impart stronger effects on risks of melanoma (RR=2.00; 95% CI, 0.9-4.6) and thyroid cancer among women who remained nulliparous (RR=4.23; 95% CI, 1.0-17.1). Gonadotropins did not increase cancer risk for these sites.

CONCLUSION

Fertility drugs do not appear to have strong effects on these cancers. Nonetheless, follow-up should be pursued to assess long-term risks and to monitor effects among women who remain nulliparous.

A mesothelial cyst of the round ligament presenting as an inguinal hernia after gonadotropin stimulation for in vitro fertilization

OBJECTIVE

To report the case of a round ligament cyst which, as the result of gonadotropin stimulation for IVF, simulated an incarcerated inguinal hernia.

DESIGN

Case report.

SETTING

A private infertility center and a university hospital.

PATIENT(S)

A 31-year-old woman who developed left lower quadrant pain after gonadotropin stimulation for IUI and a tender left inguinal mass after increasing ovarian stimulation for IVF/intracytoplasmic sperm injection.

INTERVENTION(S)

Surgical excision of a mesothelial cyst of the left round ligament and exploration of the left inguinal canal.

MAIN OUTCOME MEASURE(S)

Successful surgical excision of left inguinal mass.

RESULT(S)

Resolution of symptoms.

CONCLUSION(S)

Mesothelial cysts of the round ligament should be included in the differential diagnosis of inguinal masses in women. Gonadotropin stimulation might cause previously unrecognized cysts to simulate an incarcerated inguinal hernia, necessitating surgical repair.

Ovarian cancer risk after the use of ovulation-stimulating drugs

OBJECTIVE

To assess the long-term effects of ovulation-stimulating drugs on the risk of ovarian cancer.

METHODS

A retrospective cohort study of 12,193 eligible study subjects (median age 30 years) who were evaluated for infertility during the period of 1965-1988 at 5 clinical sites identified 45 subsequent ovarian cancers in follow-up through 1999. Standardized incidence ratios compared the risk of cancer among the infertile patients to the general population, whereas analyses within the cohort allowed the derivation of rate ratios for drug usage compared with no usage after adjustment for other ovarian cancer predictors.

RESULTS

The infertility patients had a significantly elevated ovarian cancer risk compared with the general population (standardized incidence ratio 1.98, 95% confidence intervals [CI] 1.4, 2.6). When patient characteristics were taken into account and risks assessed within the infertile women, the rate ratios associated with ever usage were 0.82 (95% CI 0.4, 1.5) for clomiphene and 1.09 (95% CI 0.4, 2.8) for gonadotropins. There were higher, albeit nonsignificant, risks with follow-up time, with the rate ratios after 15 or more years being 1.48 (95% CI 0.7, 3.2) for exposure to clomiphene (5 exposed cancer patients) and 2.46 (95% CI 0.7, 8.3) for gonadotropins (3 exposed cancer patients). Although drug effects did not vary by causes of infertility, there was a slightly higher risk associated with clomiphene use among women who remained nulligravid, based on 6 exposed patients (rate ratio 1.75; 95% CI 0.5, 5.7).

CONCLUSION

The results of this study generally were reassuring in not confirming a strong link between ovulation-stimulating drugs and ovarian cancer. Slight but nonsignificant elevations in risk associated with drug usage among certain subgroups of users, however, support the need for continued monitoring of long-term risks.

LEVEL OF EVIDENCE

II-2

Breast cancer risk associated with ovulation-stimulating drugs

BACKGROUND

Despite the recognized role of hormones in the aetiology of breast cancer, there has been little evaluation of hormonal preparations used to treat infertility.

METHODS

A retrospective cohort study of 12,193 women evaluated for infertility between 1965 and 1988 at five clinical sites identified 292 in situ and invasive breast cancers in follow-up through 1999. Standardized incidence ratios (SIRs) compared breast cancer risks with those of the general population. Analyses within the cohort estimated rate ratios (RRs) associated with medications after adjustment for other breast cancer predictors.

RESULTS

Infertile patients had a significantly higher breast cancer risk than the general population [SIR = 1.29, 95% confidence interval (CI) 1.1-1.4]. Analyses within the cohort showed adjusted RRs of 1.02 for clomiphene citrate and 1.07 for gonadotrophins, and no substantial relationships to dosage or cycles of use. Slight and non-significant elevations in risk were seen for both drugs after > or = 20 years of follow-up (RRs = 1.39 for clomiphene and 1.54 for gonadotrophins). However, the risk associated with clomiphene for invasive breast cancers was statistically significant (RR = 1.60, 95% CI 1.0-2.5).

CONCLUSIONS

Although there was no overall increase in breast cancer risk associated with use of ovulation-stimulating drugs, long-term effects should continue to be monitored.

Bilateral internal jugular venous thrombosis following successful assisted conception in the absence of ovarian hyperstimulation syndrome

The majority of the venous thromboembolic events seen in patient following gonadotropin administration were associated with the development of ovarian hyperstimulation syndrome (OHSS). However, in this case report, a 29-year-old woman that conceived by controlled ovarian hyperstimulation, intracytoplasmic sperm injection and subsequent embryo transfer without conjunction of OHSS was described. Bilateral jugular venous thrombi were detected by duplex Doppler in the 8th week of pregnancy when she was admitted to the emergency room for difficulty in swallowing and bilateral neck pain. She had unremarkable history and negative results for thrombophilia screening. Full anticoagulation with intravenous heparin was initiated and continued subcutaneously throughout pregnancy. She delivered two healthy babies at 36 weeks of pregnancy. Venous thromboembolism should be taken in account in patients undergoing gonadotropin administration for assisted conception with the complaint of extremity pain regardless of having risk factors for thromboembolism.

Bye-bye urinary gonadotrophins? Recombinant FSH: a real progress in ovulation induction and IVF?

Whether recombinant gonadotrophin products do, indeed, represent progress for routine ovulation induction and IVF cycles, in comparison with urinary products, has remained controversial. Here we review published data with regard to respective risks, outcomes and cost for both medication options. Safety considerations favour recombinant products, while overall outcome and cost considerations favour urinary gonadotrophins. Outcome, however, appears to differ, based on age and ovarian function, with younger patients benefiting from the FSH/LH combination offered by urinary products, while older women and young women with ovarian resistance, apparently benefiting from pure FSH stimulation. Young women with poor ovarian reserve may be best stimulated with a pure FSH/antagonist protocol. We conclude that under current pricing structures in the United States, recombinant gonadotrophins do not represent a major progress for the treatments of ovulation induction and IVF. They, however, allow for an improved selectivity of stimulation protocols. The creation of recombinant FSH/LH products and cost adjustments for recombinant products, may affect these conclusions in favour of recombinant products.

Minimizing risk in anonymous egg donation

Assisted conception carries with it known and putative medical and surgical risks. Exposing healthy women to these risks in order to harvest eggs for donation when a safer alternative exists is morally and ethically unacceptable. Egg sharing minimizes risk and provides a source of eggs for donation. Anonymity protects all parties involved and should not be removed.

[Bilateral internal jugular thrombosis associated with thrombophilia after ovarian induction for infertility]

Thromboembolic events are an infrequent complication of hormonal treatment for infertility and are generally related to the hyperstimulated ovarian syndrome (HOS). Jugular vein thrombosis is an unusual site of thrombosis and when present one should look for a predisposing factor. We describe a 31-year-old woman, with no previous medical history, non-smoker, who received a single cycle of hormonal stimulation for in vitro fertilisation due to primary infertility. During her eighth week of a twin pregnancy, she consulted the emergency room where the diagnosis of bilateral jugular thrombosis was confirmed, in absence of HOS or any known predisposing factor. In subsequent studies, the presence of Factor V Leyden and a mutation of G 20210 prothrombin were found. These, in association to the hormonal stimulus, were considered the risk factors. She received anticoagulation treatment with low molecular weight heparin. Screening tests for thrombophilias before hormonal treatment is not recommended, but one could consider this possibility in high-risk patients or in those who develop thrombosis in the absence of any predisposing factors.

The origin of monozygotic twinning

The incidence of monozygotic twinning appears to be increasing within the field of assisted human reproduction. Many theories have been put forward as to how and when this occurs. Whatever the cause, the normal events of embryo development, which necessarily involve axis formation, patterning and polarization, need to be adhered to in order to obtain a viable offspring. This paper describes the course of development in terms of axis formation and polarity and offers suggestions as to how either a disruption of this or duplication events in the course of the formation of these parameters could prevent or contribute to a twinning event. The likelihood of twinning occurring at any point is discussed in terms of the establishment of polarity and axes.

Is there a risk of prion disease after the administration of urinary-derived gonadotrophins?

Concern has been raised recently about the possibility of prion proteins appearing in the urine of animals and, possibly, humans affected by prion disease [scrapie, bovine spongiform encephalopathy (BSE) and Creutzfeldt Jakob disease (CJD)]. A debate has started in which the suggestion has been made that the purification of human urine for the provision of gonadotrophins should be discontinued. The alternative would be to use recombinantly-derived gonadotrophin preparations. The recombinant products, however, rely upon bovine serum during the cell culture process and could potentially also be exposed to abnormal prion proteins. It is reassuring that the different types of gonadotrophin preparations that are currently available are produced with either urine or bovine serum that is sourced from countries that at the present time appear to be free of BSE and new variant CJD. We can therefore be reassured that the gonadotrophins that we use therapeutically appear to be equally safe.

The use of urinary gonadotrophins should be discouraged

In view of concerns regarding the potential presence and infectivity of prion proteins in human urinary gonadotrophin preparations, together with the availability of both recombinant FSH and recombinant LH, it is argued that the use of urinary gonadotrophins should be discouraged.