The prognostic importance of the number of oocytes retrieved and estradiol levels in poor and normal responders in in vitro fertilization (IVF) treatment

A low response to ovarian stimulation in in vitro fertilization poses a unique therapeutic challenge. Gonadotropin-releasing hormone agonists (GnRHa) have been suggested as a modality for treatment of this condition. In this study, we analyzed the results of 880 in vitro fertilization treatment cycles with respect to modality of ovarian stimulation, degree of hormonal response, and number of oocytes retrieved. In patients with estradiol (E ₂ )levels less than 501 pg/ml on the day of human chorionic gonadotropin administration, 27% pregnancy rate was achieved with clomiphene citrate (CC) combined with human menopausal gonadotropin (hMG), compared to 15.1% (P <0.005) with hMG alone and 20.8% (NS) with GnRHa and hMG. Pregnancy rates were not lower in these patients compared to patients with higher estradiol levels in the different stimulation protocols, but pregnancy rates were significantly lower in cycles during which three or fewer oocytes were retrieved, compared to those in which four or more oocytes were retrieved (10.8 vs 23.8%; P <0.0005). In low-retrieval cycles pregnancy rates actually decreased with increasing levels of estradiol. Our results indicate that the number of oocytes retrieved is a better prognostic parameter than E ₂ levels in predicting the outcome of in vitro fertilization treatment and that GnRHa in the long protocol do not seem to be superior to CC combined with hMG for the treatment of poor responders.     

The relationship between the change in serum high sensitivity C-reactive protein levels and IVF success

The aim of this study was to assess whether the extent of the change in high sensitivity C-reactive protein (hs-CRP) levels is related with in vitro fertilization (IVF) success. A total of 69 IVF cycles using long luteal GnRH agonist protocol at the IVF unit, were prospectively studied. The serum levels of hs-CRP were measured on the day of initiation of gonadotrophin stimulation and 7 days after embryo transfer. CRP ratio was defined as the levels of CRP on day 7 of transfer/day of initiation of ovarian stimulation. Clinical pregnancy rates were examined. The mean concentrations of hs-CRP were not significantly different on the first day of ovarian stimulation and on day 7 after embryo transfer among pregnant and non-pregnant women. There was a significant rise in hs-CRP levels at 7th day after embryo transfer as compared with the first day of gonadotrophin treatment in both groups (10.58?±?11.35 versus 3.61?±?2.86?mg/L for pregnant women and 9.14?±?11.36 versus 3.24?±?2.68?mg/L for non-pregnant women, p?=?0.001). In addition, the mean CRP ratio was not different between the pregnant and non-pregnant groups. Our data show that serum hs-CRP levels increase during IVF treatment, but the extent of the rise in CRP levels is not a predictive marker of IVF success.     

The genetic risks of in vitro fertilization techniques: The use of an animal model

Purpose The influence of some technical and biological parameters on the genetic characteristics of embryos derived from in vitro fertilization (IVF) techniques was studied.Method Using a murine model, we assessed the effect of gamete manipulation, gamete maturation stage, and maternal age on the chromosome complements of firstcleavage embryos.Results and Conclusions We found a positive correlation between some of these parameters and the incidence of the different chromosome abnormalities studied. Regarding aneuploidy, we observed an influence of maternal age, using both prepubertal and old females. Polyspermy showed a positive correlation with in vitro fertilization, the immaturity and overmaturity of the oocytes employed, and the use of prepubertal females. The appearance of diploid female complements was related to oocyte immaturity and prepubertal females, while diploid male complements were directly related to in vitro fertilization. Premature chromosome condensation (PCC) had a direct relationship with oocyte immaturity and in vitro maturation of the oocyte. Finally, structural abnormalities were associated with the process of sperm aging in vitro.     

The need to step up the gonadotropin dosage in the stimulation phase of IVF treatment predicts a poor outcome

Purpose It is a common practice to increase the gonadotropin dose during ovarian stimulation when the estradiol (E₂) rise is found to be inadequate. The prognostic impact of the use of this step-up regimen on the outcome of the affected in vitro fertilization (IVF) cycle is the subject of this study. Methods This is a retrospective analysis of IVF cycles in a series of consecutive patients who required an increase in the gonadotropin dosage during the stimulation phase because of inadequate E₂ rise. Controls consisted of patients in whom the dose was not increased. After 4 days of stimulation, the gonadotropin dosage was increased if E₂ levels failed to rise by 70% every 2 days. Outcome was defined in terms of maximum E₂ level, number of follicles at aspiration, number of oocytes obtained, fertility rate, and pregnancy rate and was compared in study and control patients. Pregnancy was defined by sonographic demonstration of cardiovascular activity. Results One hundred forty-five patients were analyzed. A stepup regimen was used in 35 patients (24.1%). Patients who required the step-up dosing had significantly lower peak E₂ levels (1373 vs 1828 pg/ml; P < 0.005), fewer follicles measuring greater than 16 mm (7.2 vs 9.7; P < 0.003), and fewer oocytes recovered (8.3 vs 11.2; P < 0.009). The fertilization rate (67.6 vs 64.2%) was not significantly different. The pregnancy rate (8.5 vs 32.7%; P < 0.004) was significantly lower in the group requiring the stepup regimen. Conclusions The utilization of a step-up regimen during an IVF treatment cycle is a predictor of a poor outcome for the specific IVF cycle. As this information is available before retrieval, consideration of cycle cancellation may be appropriate.     

Transient hyperprolactinemia has no effect on endocrine response and outcome in in vitro fertilization (IVF)

Transient rises in plasma prolactin levels can be observed during the late follicular phases of both natural and stimulated cycles. It has been suggested that such a phenomenon might adversely affect the success of in vitro fertilization. This prospective study was designed to assess the effect of transient rises in prolactin levels on the endocrine response to ovarian stimulation and the outcome of in vitro fertilization treatment. A total of 90 treatment cycles in 87 couples was studied. Prolactin was measured in the mid and late follicular phases of the cycles. During the study period, 24 pregnancies occurred. There were no differences in those cycles in which pregnancy did or did not occur in either mid or late follicular prolactin levels. Neither the initial level nor the percentage rise in prolactin during the stimulation had any effect on the peak estradiol level achieved, the numbers of follicles seen, the number of eggs retrieved, or the incidence or outcome of pregnancy. It was concluded that transient hyperprolactinemia is of no significance in ovarian stimulation for in vitro fertilization.     

Effects of luteal estradiol pre-treatment on the outcome of IVF in poor ovarian responders

Background: In view of the discrepancies about the luteal estradiol treatment before stimulation protocols having some potential advantages compared with the standard protocols in poor ovarian responders undergoing IVF, a meta-analysis of the published data was performed to compare the efficacy of the luteal estradiol pre-treatment protocols in IVF poor response patients. Methods: We searched for all published articles. The searches yielded 32 articles, from which seven studies met the inclusion criteria. We performed this meta-analysis involving 450 IVF patients in luteal estradiol pre-treatment protocol group and 606 patients in standard protocol group. Results: The luteal estradiol protocol resulted in a significantly higher duration of stimulation compared with the standard protocol. In addition, the number of oocytes retrieved and mature oocytes retrieved were significantly higher in the luteal estradiol protocols than those in the standard protocols. The cycle cancellation rate (CCR) in the luteal estradiol protocols was lower than the standard protocols. Moreover, no significant difference was found in the clinical pregnancy rate (CPR). Conclusions: The addition of the estradiol in the luteal phase preceding IVF in poor responders improved IVF cycle outcomes, including increasing the number of oocytes retrieved and mature oocytes retrieved and decreasing the CCR.     

Chromosome 21 Detection in Human Oocyte Fluorescence In Situ Hybridization: Possible Effect of Maternal Age

Purpose: The purpose of this study was to evaluate, among 100 uncleaved oocytes, the incidence of numerical and structural chromosome 21 and X abnormalities and to analyze the influence of various factors, such as in vitro (IVF) indications, follicle stimulation protocols, and women's age. Methods: We investigated 150 uncleaved oocytes from 128 patients after an IVF attempt. After cytogenetic analysis (Giemsa) 100 oocytes (66%) were selected for fluorescence in situ hybridization (FISH). Fluorescent probes for human chromosomes X and 21 were used simultaneously according to standard procedures for their hybridization and detection. Results and Conclusions: We analyzed by the FISH protocol 100 metaphase II oocytes with 22 to 25 chromosomes. Our results demonstrate a high rate of disomy for chromosome 21 in human oocytes. Among them, eight were disomic (8%) and three were nullosomic (3%) for chromosome 21. Only one disomy of chromosome X was noted. The various indications of IVF and the different folliculogenesis stimulating protocols did not seem to influence the results but suggested a correlation between the maternal age and the aneuploidy rate of chromosome 21.     

Selection of ovarian stimulation protocol is related to IVF treatment outcome in women 35 years of age and older

Purpose The aim of this study was to assess if the woman's age influenced IVF treatment outcome when a long GnRHa-hMG or a CC-hMG ovarian stimulation protocol was used. Two hundred women were included in the study, 100 women under the age of 35 and 100 women 35 years of age and older (mean 31.8 years and 36.7 years respectively). In the younger group as well as in the older group 50 women were stimulated according to a GnRHahMG protocol and 50 women received a CC-hMG regimen.Results Significant differences between stimulation protocols were found in the older group for the mean numbers of oocytes recovered (4.7 vs 3.0), preembryos obtained (3.2 vs 2.0) and replaced (2.3 vs 1.7), as well as pregnancy (30 % vs 10 %) and delivery (24 % vs 4 %) rates per replacement.Conclusion It is concluded that women over 35 years of age seem to have a more favorable outcome of IVF treatment when using a long GnRHa-hMG protocol compared with CC-hMG, while this difference was not as obvious and lacking statistical significance under the age of 35.     

Preretrieval predictors of pregnancy in IVF

Purpose: This study was designed to evaluate the predictive value of preretrieval parameters of ovarian stimulation in patients undergoing IVF-ET. Methods: Women diagnosed with infertility due to tubal factor were compared to women with other and/or multiple diagnoses. Stepwise logistic regression evaluated 389 cycles to identify the best predictors of pregnancy among the following variables: age, primary or secondary infertility, cycle number, type and dose of gonadotropin, duration of gonadotropin administration, serum estradiol level, and number and size of follicles. Results: In the tubal disease group, probability of pregnancy was greater in cycles with serum estradiol levels below 1100 pg/ml on the day of hCG (odds ratio, 4.7) and with administration of gonadotropins for less than 10 days (odds ratio, 3.7). In contrast, in the other/mixed diagnoses group, a serum estradiol below 1100 pg/ml was associated with a decreased probability of pregnancy (odds ratio, 0.6). Conclusions: Optimal parameters of ovarian stimulation may vary according to the etiology of infertility. In patients with tubal disease, the beneficial effects of greater stimulation, and thus the greater number of available oocytes, may be offset by adverse effects on the endometrium and on the quality of oocytes and embryos. In contrast, in other diagnostic groups, the advantage of an increased number of oocytes may outweigh the potential adverse effects of prolonged stimulation and higher estradiol levels.     

Reproductive Performance of Couples Discordant for Hepatitis B and C Following IVF Treatment

PURPOSE: To examine the reproductive performance of hepatitis B (HBV) and C (HCV) discordant couples following IVF-ET. METHODS: A retrospective cohort study of 25 IVF-ET cycles in HBV and HCV discordant couples was performed. Thirteen patients in the study cohort were discordant for HBV (10 males and 3 females), and 12 (9 males and 3 females) for HCV. Twenty-seven consecutive age matched patients comprised the control group. All patients underwent controlled ovarian hyperstimulation using the long downregulation protocol followed by IVF or ICSI. RESULTS: Patients in the three groups (HBV, HCV, and controls) had similar ages, and day 3 FSH concentrations. Despite comparable response to COH, and similar fertilization, and cleavage rates in the three groups, couples discordant for HBV or HCV had significantly poorer implantation and pregnancy rates (7.7%, 0% respectively) compared with controls (41%). CONCLUSIONS: Despite comparable response to COH, HBV and HCV positive discordant couples, have significantly lower implantation and pregnancy rates compared with age-matched controls.     

Outcomes from ovarian hyperstimulation following the sole administration of gonadotrophin-releasing hormone agonist in the context of in vitro fertilization: report of two cases and review of the literature

Objective: To report the outcomes from two cases of ovarian stimulation following the sole administration of gonadotrophin-releasing hormone agonist (GnRHa) in the context of in vitro fertilization (IVF). Design: A case study was conducted. Setting: National Referral Unit of Reproductive Medicine. Patients: Two infertile women undergoing IVF participated in the study. Interventions: Controlled ovarian hyperstimulation using a long protocol. GnRHa (Buserelin) was started in the luteal phase, in a dose of 600 µg/day, for 12 days. Main outcome measures: Number of retrieved oocytes, fertilization rate, number of embryos transferred, implantation rate, ongoing pregnancy, and live birth. Results: Both women underwent egg retrieval and transfer of good quality embryos. One of them conceived and recently gave birth to a healthy full-term baby. Conclusions: The ovarian hyperstimulation after the sole administration of GnRHa is a rare condition. Oocyte retrieval may be a reasonable treatment under these circumstances instead of cycle cancellation. As far as it is known, this is the third case reported of a live birth following the sole administration of GnRHa in the context of IVF.     

A friendly IVF protocol

Objective

To compare the results of a Minimally stimulated Natural cycle IVF with standard long protocol IVF.

Design

A Prospective Study Setting: Private Fertility Institute

Patient(s)

A total of 300 women were recruited of whom 150 cases [Group A] underwent IVF with minimally stimulated natural cycle and 150 controls [Group B] underwent IVF with standard long protocol, with cases and control matched for age, infertility cause, baseline FSH, ovarian reserve and no known male factor as a cause of infertility.

Result(s)

The number of oocytes retrieved was significantly lower for the minimally stimulated natural cycle regimen compared with the standard long protocol[ 4.8 ± 2.6 vs 16.2 ± 7.5 respectively]. The clinical pregnancy rate per transfer, however, was not significantly different between the two regimens [37% Vs 41%, minimally stimulated natural cycle Vs Standard long protocol, respectively].

Conclusion (s)

Minimally stimulated natural cycle IVF is a viable alternative with comparable pregnancy rates to the standard long protocol, and with added advantages of close to zero multiple pregnancy rate, zero risk of ovarian hyper stimulation syndrome, less time consuming, physically and emotionally less demanding for patients and also cost effective.     

Comparison of clinical outcomes among dual ovarian stimulation,mild stimulation and luteal phase stimulation protocols in women with poor ovarian response

This study aimed to determine whether consecutive ovarian stimulation in follicular and luteal phases within a single menstrual cycle (dual stimulation) is achievable and superior to conventional stimulation for poor ovarian responders (PORs). Data of 260 PORs were retrospectively collected and divided into three groups. Group A comprised of cycles with dual ovarian stimulation (n?=?76), which were divided into two subgroups (follicular [group A-F] and luteal phase stimulation [group A-L]); group B comprised of cycles with ovarian stimulation that was performed only in the luteal phase (n?=?52). Group C comprised of mild ovarian stimulation cycles (n?=?132). Baseline parameters were not different among the three groups. The numbers of oocytes and embryo obtained were less in group A-F than group B and C, while group A overall had significantly more oocytes and viable embryo retrieved than did group B and C. Group A-L consumed significantly less gonadotropin than group B, without compromising the number of retrieved oocytes and embryo. The pregnancy outcomes of transfer of embryo from different stimulation phases were similar. We conclude that dual ovarian stimulation protocol is effective and potentially optimal for PORs.     

Comparison of outcomes and direct cost between minimal stimulation and conventional protocols on ovarian stimulation in in vitro fertilization

AIM: To determine whether minimal stimulation with clomiphene and gonadotropin provides outcomes and direct costs comparable with those of a conventional GnRHa-gonadotropin stimulation protocol for infertile patients undergoing in vitro fertilization. METHODS: A non-randomized clinical trial was conducted from 1 July 1996 to 31 March 2003 at the Infertility and Assisted Reproductive Unit, Ramathibodi Hospital, Faculty of Medicine, Mahidol University, Thailand. A total of 192 patients were recruited of whom 96 cases underwent ovarian stimulated cycles with minimal stimulation protocol, and 96 controls underwent ovarian stimulated cycles with GnRHa-gonadotropin protocol, with cases and controls matched for age and infertility cause. RESULTS: The median patient age was 35 years. Endometriosis was the most frequent infertility cause (28.1%). The conventional GnRHa-gonadotropin protocol could give more oocyte numbers than the minimal stimulation protocol (7.3 +/- 4.9 vs 4.5 +/- 3.3 oocytes). The fertilization rate and cleavage rate were similar (73.4 +/- 31.9 and 84.9 +/- 32.6 in minimal stimulation protocol, 69.3 +/- 29.6 and 88.4 +/- 28.0 in GnRHa-gonadotropin protocol, respectively). The pregnancy rate per oocyte retrieval cycle in the GnRHa-gonadotropin protocol was similar to the minimal stimulation protocol. (13.1%vs 13.0%, P = 1.000). However, the cost per pregnancy of minimal stimulation protocol was less than that of GnRHa-gonadotropin protocol. (6021.95 US dollars for minimal stimulation protocol per pregnancy, 10,785.65 US dollars for GnRHa-gonadotropin protocol per pregnancy, P < 0.000). CONCLUSION: Minimal stimulation was less effective than conventional GnRHa-gonadotropin on the ovarian stimulation. However, the total costs of minimal stimulation were cheaper than the conventional GnRHa-gonadotropin protocol. The decreased costs of minimal stimulation justifies further evaluation of its role in the treatment of infertility in selected cases.     

Single and Repeated GnRH Agonist Stimulation Tests Compared With Basal Markers of Ovarian Reserve in the Prediction of Outcome in IVF

Purpose: To study the value of a single or repeated GnRH agonist stimulation test (GAST) in predicting outcome in IVF compared to basal ovarian reserve tests.Methods: A total of 57 women was included. In a cycle prior to the IVF treatment, on day 3, an antral follicle count (AFC) was performed and blood taken for basal FSH, inhibin B and E₂ measurements, followed by a subcutaneous injection of 100 g triptorelin for the purpose of the GAST. Twenty-four hours later blood sampling was repeated. All the tests were repeated in a subsequent cycle. From the GAST E₂ and inhibin B response were used as test parameters. The outcome measures were poor ovarian response and ongoing pregnancy. Group comparisons were done using the Mann– Whitney or chi-square test. Univariate and multivariate logistic regression was applied to assess which test revealed the highest predictive accuracy as expressed in the area under receiver-operating characteristic curve (ROC_AUC). Clinical value was compared by calculating classical test characteristics for the best logistic models.Results: All the basal and GAST variables were significantly different in the poor responders (n = 19) compared to normal responders (n = 38). In the univariate analysis on cycle 1 tests the AFC was the best predictor for poor ovarian response, while in cycle 2 the E₂ response in the GAST performed best (ROC_AUC of 0.91 for both). Multivariate analysis of the basal variables led to the selection of AFC and inhibin B in cycle 1, yielding a ROC_AUC of 0.96. Mean E₂ response was selected in a multivariate analysis of the repeated GAST variables (ROC_AUC 0.91). At a specificity level of 0.90, several logistic models including GAST variables appeared to have a sensitivity (0.80), positive predictive value (0.82) and false positive rate (0.18), comparable to a logistic model containing AFC and inhibin B. None of the test variables showed a significant relation with ongoing pregnancy.Conclusions: The GAST has a rather good ability to predict poor response in IVF. However, comparing the predictive accuracy and clinical value of the GAST with a day 3 AFC and inhibin B, it appeared that neither a single nor a repeated GAST performed better. In addition, the predictive ability towards ongoing pregnancy is poor. Therefore, the use of the GAST as a predictor of outcome in IVF should not be advocated.     

In vitro DNA fluorescence after in vitro fertilization (IVF) failure

Purpose A pilot study was performed to test the diagnostic value of in vitro DNA fluorescence in oocytes that failed to fertilize after IVF. Ten patients with a cleavage rate less than 20% after IVF were included.Results Uncleaved oocytes were observed by fluorescence microscopy after incubation with the DNA fluorescent dye Hoechst 33342. Four main causes which may have contributed to the low cleavage rate were found: (1) sperm incapacity to penetrate the oocyte despite the absence of the usual criteria for male infertility, (2) oocyte immaturity, (3) delayed fertilization, and (4) oocyte abnormalities revealed by aberrations in the morphology of the female chromatin.Conclusions The possibility of a rapid and detailed analysis of the maturational status of unfertilized oocytes, the morphology of the female chromatin, the presence and quantity of spermatozoa tightly bound to the zona pellucida, and sperm penetration into the oocyte without subsequent pronucleus formation, using DNA fluorescence, allows us to clarify further the cause of fertilization failure and to orient infertility treatment toward the male, the female, or both partners.     

Influence of advanced age on the blastocyst development rate and pregnancy rate in assisted reproductive technology

Objective: To evaluate the percentage of blastocysts developing, the pregnancy rate, the implantation rate, and the abortion rate in women >40 years of age using a cell-free culture system for the development of viable human blastocysts.

Design: Retrospective clinical study.

Setting: Private IVF units.

Patient(s): Two hundred ninety-three cycles in patients undergoing IVF treatment for infertility. Sixty-two cycles were in patients ≥40 years of age, and 231 cycles were in patients <40 years of age.

Intervention(s): Pronucleate oocytes obtained from IVF were cultured in vitro for 5–6 days. One to four embryos were transferred.

Main Outcome Measure(s): Blastocyst development rate, pregnancy rate, implantation rate, and abortion rate.

Result(s): From 293 cycles, 3,115 pronucleate oocytes were cultured, producing 1,175 blastocysts. In the women >40 years of age, the blastocyst development rate was 22.2%, and in the younger group, the rate was 40.5%. The pregnancy rate and implantation rate in the ≥40-year age group were 21.1% and 8.9%, respectively; corresponding rates in the younger group were 44.6% and 19.9%. The abortion rate was increased for the ≥40-year age group (25% versus 13.3%).

Conclusion(s): Success rates for the development of viable human blastocysts, pregnancy, and implantation decline significantly in women ≥40 years old.