口服避孕药预处理在卵巢功能储备良好而前次IVF失败患者中的应用效果

目的:评估口服避孕药(OC)预处理在卵巢储备良好、前次IVF失败患者中的应用效果。方法:回顾分析131例卵巢储备功能良好、前次IVF常规黄体中期降调节长方案失败再次行助孕治疗的患者资料,其中口服避孕药预处理后长方案治疗52例为研究组,黄体中期长方案治疗79例为对照组。结果:研究组降调节后LH值明显低于对照组,双原核(2PN)率和卵裂率明显高于对照组,可利用胚胎数明显高于对照组(P<0.05);但Gn使用时间、Gn使用量、获卵数、MII卵数、移植日子宫内膜厚度、生化及临床妊娠率、因OHSS倾向取消移植率与对照组比较均无明显统计学差异(P>0.05)。结论:在有自发排卵的卵巢储备功能良好、前次IVF常规长方案失败、再次选用长方案超促排卵(COH)治疗的患者中,使用OC预处理能够降低降调节后LH值,改善正常受精率,增加可利用胚胎数,是值得推荐的治疗方案。     

Mini-dose GnRH-a long versus short protocol in patients ≥35 years old undergoing in vitro fertilization

Purpose: To compare the clinical result of mini-dose GnRH-a long protocol with short protocol in older patients undergoing IVF.

Materials and methods: This was a retrospective study. Four hundred and sixty-one women aged above 35-year-old in first cycle were assigned to two groups: GnRH-a short protocol (n?=?359); and mini-dose GnRH-a long protocol (n?=?102). Both groups were divided based on their age, into groups over and under 38 years old. Primary outcome include live birth rate per started cycle. Other clinical outcomes were good-quality embryo rate, clinical pregnancy rate.

Results: Patients treated with mini-dose GnRH-a protocol and those treated with short protocol showed similar live birth rate. In the mini-dose long protocol group aged 35–38 years old, patients showed significantly thicker endometrium at the day of hCG administration, higher number of good embryos obtained and higher good-quality embryo rate (56.3% versus 46.5%) compared with short protocol. The implantation rate and clinical pregnancy rate were higher versus short protocol group, but this result was not statistically significant.

Conclusion(s): Mini-dose GnRH-a long protocol for older women is at least as effective as short protocol, especially in patients aged 35–38 years, with a better good-quality embryo rate and higher number of good embryos obtained, therefore mini-dose GnRH-a long protocol can be considered as an alternative protocol for patients above 35 years age.     

Does oral contraceptives pretreatment affect the pregnancy outcome in polycystic ovary syndrome women undergoing ART with GnRH agonist protocol?

This study aims to investigate whether oral contraceptive pills (OCP) pretreatment impairs pregnancy outcomes in polycystic ovary syndrome (PCOS) women undergoing GnRH agonist protocol. A total of 1025 couples underwent their first cycle of in vitro fertilization. Patients were divided into GnRH agonist protocol group (LP group) and OCP dual suppression GnRH agonist protocol group (OC-LP group). Logistic regressions were performed to estimate the risk factors affecting live birth following fresh embryo transfer between groups. Frozen–thawed embryos from the first oocyte retrieval cycle were replaced into uterus for women did not get live birth. Cumulative live birth rates between groups were compared by Kaplan–Meier survival analysis. Serum luteinizing hormone level, endometrial thickness, and live birth rate were significantly reduced in the OC-LP group in fresh cycle. Thinner endometrium, higher progesterone, and poorer embryo quality were independent risk factors for failure in getting live birth following fresh embryo transfer. However, cumulative live birth rate, medium embryo transfer attempts required to achieve live birth were comparable between groups. OCP pretreatment in GnRH agonist protocol does not seem to impair the pregnancy outcome when calculated by cumulative live birth rate in PCOS women.     

Agonist depot versus OCP programming of frozen embryo transfer: a retrospective analysis of freeze-all cycles

Purpose

In segmented ART treatment or so-called ‘freeze-all’ strategy fresh embryo transfer is deferred, embryos cryopreserved, and the embryo transferred in a subsequent frozen embryo transfer (FET) cycle. The purpose of this cohort study was to compare a GnRHa depot with an oral contraceptive pill (OCP) programming protocol for the scheduling of an artificial cycle FET (AC-FET) after oocyte pick-up (OPU).

Methods

This retrospective cohort study was conducted on prospectively performed segmented ART cycles performed between September 2014 and April 2015. The pregnancy, treatment duration, and cycle cancellation outcomes of 170 OCP programmed AC-FET cycles were compared with 241 GnRHa depot programmed AC-FET cycles.

Results

No significant difference was observed in the per transfer pregnancy and clinical pregnancy rates between the OCP and GnRHa groups, 72.0 versus 77.2 %, and 57.8 versus 64.3 %, respectively. Furthermore, the early pregnancy loss rate was non-significantly different between the OCP and GnRH protocol groups, 19.8 versus 16.7 %, respectively. However, nine (5.29 %) cycles were cancelled due to high progesterone in the OCP protocol group, while no cycles were cancelled in the GnRHa protocol group and the time taken between OPU and FET was 19 days longer (54.7 vs 35.6 days) in the OCP protocol compared to the GnRHa protocol.

Conclusions

The results of this AC-FET programming study suggests that the inclusion of GnRHa depot cycle programming into a segmented ART treatment will ensure pregnancy, while significantly reducing treatment duration and cycle cancellation.

     

Hypothalamic-pituitary suppression with oral contraceptive pills does not improve outcome in poor responder patients undergoing in vitro fertilization-embryo transfer cycles

Purpose: To evaluate and compare the use of OCP with GnRHa for hypothalamic-pituitary suppression in poor responder IVF patients. Methods: Retrospective analysis of IVF-ET cycles of poor responders. Hypothalamic-pituitary suppression with OCP (Group I, n = 29) or GnRHa (Group II, n = 52), followed by stimulation with gonadotropin, oocyte retrieval, and embryo transfer. Baseline characteristics and cycle outcomes were compared. Results: 73 women underwent 81 cycles from 1/1/1999 to 1/1/2000. Baseline characteristics were similar. 31/81 (38%) cycles were cancelled (Group I, 14/29 (48%) vs. Group II, 17/52 (33%), NS). Cycle outcomes including amount of gonadotropin, number of eggs retrieved, number of embryos transferred, and embryo quality were similar. Patients in Group I required fewer days of stimulation to reach oocyte retrieval. Pregnancy outcomes were similar in the two groups. Conclusion: Our retrospective analysis revealed no improvement in IVF cycle outcomes in poor responders who received OCPs to achieve hypothalamic-pituitary suppression instead of GnRHa.     

A novel strategy of using corifollitropin alfa in the ultrashort gonadotropin-releasing hormone agonist (GnRHa) protocol in unselected patients: A patient-friendly alternative

ObjectiveTo compare the outcomes of in vitro fertilization (IVF) and fresh embryo transfer (ET) using corifollitropin alfa in ultrashort gonadotropin-releasing hormone agonist (GnRHa) protocol and GnRH antagonist protocol.Materials and methodsA total of 245 unselected patients undergoing IVF/fresh ET were enrolled between January 1 and December 31, 2017, including 135 treated with ultrashort GnRHa protocol and 110 treated with antagonist protocol. The primary outcomes were number of total injections and outpatient department (OPD) visits before ovulation triggering. The secondary outcomes were the duration of stimulation, dosage of additional gonadotropin for ovarian hyperstimulation, rates of pregnancy, clinical pregnancy, live birth, ovarian response, and ovarian hyperstimulation syndrome (OHSS) rate.ResultsPatients treated with ultrashort GnRHa required less additional gonadotropin, fewer total injections, but had better ovarian responses, including more oocytes retrieved, more metaphase II oocytes, and more blastocysts than those treated with antagonist did. A premature LH surge occurred only in six patients treated with antagonist protocol. The rates of pregnancy (37.0% vs. 43.6%), clinical pregnancy (25.2% vs. 34.6%), and live birth (19.3% vs. 30.0%) did not differ significantly between the two groups. The OHSS rate was similar in the two groups.ConclusionIn unselected patients using corifollitropin alfa, the ultrashort GnRHa protocol needed lower dose of additional gonadotropin and fewer injections but produced similar pregnancy outcomes than antagonist protocol did, suggesting that the ultrashort GnRHa protocol could be an alternative.     

Does stress affect IVF outcomes? A prospective study of physiological and psychological stress in women undergoing IVF

Research questionWhat are the effects of physiological and psychological stress on fertility outcomes for women undergoing IVF?DesignA prospective cohort study of 72 patients undergoing IVF in 2017 and 2018. Physiological stress was assessed by salivary cortisol measurements: (i) pretreatment, when the patient received the IVF protocol; (ii) before oocyte retrieval (follicular cortisol was also measured); and (iii) before embryo transfer. Emotional stress was evaluated at each assessment with the State-Trait Anxiety Inventory and a 1–10 Visual Analogue Scale (VAS, referred to as the ‘Stress Scale’. Correlations between cortisol concentrations, psychological stress and IVF outcome were assessed.ResultsSalivary cortisol concentrations increased by 28% from pretreatment phase (0.46 ± 0.28 μg/dl) to maximum concentration on oocyte retrieval day (0.59 ± 0.29 μg/dl, P = 0.029) and then decreased by 29% on embryo transfer day (0.42 ± 0.23 μg/dl, P = 0.0162). On embryo transfer day, cortisol among women in their first cycle was higher than women who underwent more than one treatment (P = 0.024). Stress Scale score increased by 39% from pretreatment to a maximum score on oocyte retrieval day and then decreased by 12% on embryo transfer day. Salivary cortisol and Stress Scale were not related to subsequent embryo transfer, fertilization rate, embryo quality or clinical pregnancy rate. Follicular cortisol concentration was positively correlated with fertilization rate (r = 0.4, P = 0.004).ConclusionIt can be cautiously concluded that physiological and psychological stress do not negatively affect IVF outcomes. Moreover, high follicular cortisol concentrations might have positive effects on pregnancy rates.     

3种控制性促排卵方案治疗卵巢反应不良效果的比较

目的:探讨3种控制性促排卵方案治疗卵巢反应不良年轻患者的效果。方法:回顾分析2009年6月至2011年7月在中山大学附属第一医院生殖中心行辅助生育治疗、年龄30～40岁、出现2次及以上卵巢反应不良周期患者的所有周期共240个,选取其中标准GnRH激动剂长、短及拮抗剂方案共220个周期。在220个周期中GnRH激动剂长方案86个周期为长方案组、短方案83个周期为短方案组、拮抗剂方案51个周期为拮抗剂方案组。比较3组病例的临床资料、实验室资料和妊娠结局,评估不同促排卵方案治疗卵巢反应不良的结果。结果:短方案组基础FSH高于长方案组(P=0.039),但Gn总量少于长方案组(P=0.000),两组胚胎质量及妊娠结局的差异无统计学意义。短方案组基础FSH与拮抗剂方案组的差异无统计学意义,虽然Gn使用量高于拮抗剂方案组(P=0.000),但获卵数亦高于拮抗剂方案组(P=0.001),且周期取消率低于拮抗剂方案组(P=0.013)。3组其他临床资料(年龄、不孕年限等)、受精数、受精率、可利用胚胎率、胚胎种植率及妊娠结局等差异均无统计学意义(P>0.05)。比较添加生长激素对长、短方案获卵数的影响,差异无统计学意义(P>0.05)。结论:GnRHa短方案用于小于40岁的卵巢反应不良患者的促排卵效果较优。     

Cessation of Low-Dose Gonadotropin Releasing Hormone Agonist Therapy Followed by High-Dose Gonadotropin Stimulation Yields a Favorable Ovarian Response in Poor Responders

Purpose: This study is a prospective nonrandomized study to determine the effect of a new protocol of controlled ovarian hyperstimulation (COH) using low doses and a half-period of gonadotropin releasing hormone agonist (GnRHa) followed by high doses of gonadotropin in patients who were supposed to be poor responders to standard long protocols of GnRHa administration. Methods: From Dec 1996 to Nov 1998, 50 patients who were classified as poor responders were scheduled for 52 cycles of a modified controlled ovarian hyperstimulation protocol. They were categorized into 3 groups: a group of poor responders to COH in the previous IVF or IUI cycles, a group with elevated Day 3 FSH levels, and a group over the age of 40 years. All patients received GnRH agonist from the midluteal phase of the previous cycle to the onset of menstruation in the next cycle. Then high doses of gonadotropins (HMG/FSH) were given. The patients then had standard courses of in vitro fertilization and embryo transfer (IVF-ET) or transfallopian embryo transfer (TET). Results: Six of the 52 cycles of the modified protocols were cancelled because of poor ovarian response. One premature ovulation was noted before ovum retrieval was performed. In the other 45 cycles, an average of 6.3 mature oocytes were retrieved. The total pregnancy rate and implantation rate were 20.5 and 11.5%, respectively. Conclusions: The low dose and half duration of GnRHa therapy lessened the suppression of the response of the ovaries to COH compared with the regular long protocol of GnRHa down regulation therapy. This resulted in a low cancellation rate (11.8%), a favorable embryo implantation rate (11.5%), and an acceptable clinical pregnancy rate (20.5%).     

Segmented in vitro fertilization and frozen embryo transfer in dienogest-treated patient with adenomyosis: A case report and lierature review

ObjectiveTo assess the effects of dienogest on segmented in vitro fertilization (IVF) and frozen-thawed embryo transfer (FET) for a patient with adenomyosis.Case reportA 33-year-old female with primary infertility for 3 years had dysmenorrhea and hypermenorrhea. Diagnosis of adenomyosis was made with a sonographic exam and an elevated cancer antigen 125 (CA-125, 310 U/mL). Her early follicular hormone profile (anti-müllerian hormone, AMH, 8 ng/mL) was normal. After repeated controlled ovarian stimulation (COS) and failed intrauterine insemination (IUI), she underwent IVF. Controlled ovarian stimulation using gonadotropin-releasing hormone (GnRH) antagonist protocol was performed with the blastocyst freeze-all IVF cycle. Pretreatment with two months of GnRH agonist (GnRHa) and frozen-thawed embryo transfer did not result in pregnancy. Subsequently, three months of long-term pretreatment with dienogest was given, and the CA-125 level was markedly reduced. Frozen-thawed blastocyst stage embryo transfer was provided, and a singleton pregnancy was achieved.ConclusionDienogest, a novel progestin highly selective for progesterone receptors, may benefit the pregnancy outcomes of infertile patients with adenomyosis adopting segmented IVF with FET.     

长效和短效GnRH-a在IVF/ICSI周期长方案中的应用比较

目的:探讨长效和短效促性腺激素释放激素激动剂(GnRH-a,曲普瑞林)在体外授精/卵细胞浆内单精子注射(IVF/ICSI)周期长方案中的应用及其对临床结局的影响。方法:对排卵正常者采用黄体中期降调长方案,无排卵者行口服避孕药(OC)预处理长方案,根据采用不同的剂型分为长效GnRH-a组和短效GnRH-a组,对两组在应用过程中的检测值进行比较。结果:无论黄体中期降调长方案,还是OC预处理长方案,其长效GnRH-a组的Gn用量和Gn天数,注射绒促性素(HCG)日血孕酮水平均明显高于短效GnRH-a组(P<0.05,P<0.01),长效GnRH-a组妊娠率和种植率明显低于短效GnRH-a组(P<0.05)。两种方案中,长效和短效GnRH-a组间按主导卵泡平均直径范围(≥18mm～≤20mm、>20mm～≤22mm和>22mm)比较,各直径范围中周期所占比例差异无统计学意义(P>0.05)。结论:长方案中使用长效GnRH-a降调比短效会增加Gn用量,使孕酮水平升高,妊娠率和种植率降低,对临床结局有不利影响。     

GnRH Antagonist Improved Blastocyst Quality and Pregnancy Outcome After Multiple Failures of IVF/ICSI–ET with a GnRH Agonist Protocol

BACKGROUND: To determine the efficacy of a gonadotrophin-releasing hormone (GnRH) antagonist, cetrorelix, in improving the quality of embryos and pregnancy outcome, we performed a study in patients with a history of multiple failures of in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) cycles with a GnRH agonist (GnRHa) long protocol. METHODS: Forty women with no live births after conventional IVF or ICSI embryo transfer (ET) and subsequent blastocyst transfer (BT) with a GnRHa long protocol entered this study. The treatment protocol consisted of a daily dose of clomiphene citrate 100 mg for 5 days and gonadotrophin injections daily from cycle day 4 onward. Cetrorelix, 0.25 mg/day, was started when the leading follicle reached 14 mm. Induction of ovulation was triggered with human chorionic gonadotrophin (HCG) (N = 36) or GnRHa (N = 4). It was possible to perform BT in 38 patients. RESULTS: Comparison of the results with the results for BT with the previous GnRHa protocol showed no significant differences in number of oocytes retrieved or the zygote- and blastocyst-development rate. With the cetrorelix protocol, however, number of patients whose embryos had developed to at least one expanded blastocyst on day 5 was significantly higher than with the GnRHa protocol (25 vs. 9) (p < 0.001), and 16 of the women became pregnant (42.1%), with 7 delivering 9 infants, 4 ending in abortion (25%), and 5 in progressing. CONCLUSIONS: The use of a GnRH antagonist in controlled ovarian hyperstimulation improves the outcome of pregnancy of patients with a history of multiple failure of IVF/ICSI-ET in a GnRHa protocol, most likely due to improvement of the quality of the blastocysts generated.     

Contamination of Embryo Transfer Catheter and Treatment Outcome in In Vitro Fertilization

Purpose: The effect of embryo transfer (ET) catheter contamination with mucus and/or blood on treatment outcome in an in vitro fertilization (IVF) program was evaluated. Methods: One thousand four ET procedures in 877 patients having conventional IVF in the long (1189 cycle) and short (15 cycles) protocol were analyzed to determine the impact of catheter contamination on the Incidence of retained embryos and the clinical pregnancy rate. Results: Catheter contamination with mucus and/or blood is a feature of difficult ET. Embryos were significantly more likely to be retained when the transfer catheter was contaminated with mucus (17.8 versus 3.3%) or blood (12 versus 3.3%). When the catheter was contaminated and an embryo(s) was retained and immediately retransferred, the pregnancy rate was not compromised. The pregnancy rate was significantly reduced when the ET catheter was contaminated with blood (15.5 versus 27.1%;P = 0.002), but no embryo was retained in the catheter set. Conclusions: Catheter contamination compromises the treatment outcome in IVF only when there is no associated retained embryo(s). As increased vigilance in searching for extruded embryos may not be practical, we suggest that cervical mucus should be routinely aspirated and ET performed as atraumatically as possible.     

Effect of normal sperm morphology rate (NSMR) on clinical outcomes and fertilization methods selection in the ultra-short-term GnRH-a protocol

Purpose: To investigate whether intracytoplasmic sperm injection (ICSI) can improve the clinical outcomes of the male patients with teratozoospermia in the ultra-short term GnRH-a protocol.

Methods: Based on different normal sperm morphology rate (NSMR), the patients were divided into three groups as follows: NSMR?=?0% group, 1% ≤NSMR <4% group and NSMR ≥4% group. Each group was compared with two fertilization type of in-vitro fertilization (IVF) and ICSI separately. Main outcomes compared were normal fertilization, high-quality embryo, transferrable embryo, implantation, pregnancy and abortion rate.

Results: We observed that the total clinical pregnancy rate in single cleavage-stage embryo transfer (SET) group was significantly lower compared with double cleavage-stage embryo transfer (DET) group (23.87% versus 40.08%; p?p?>?0.05). The normal fertilization, high-quality embryo, transferrable embryo, implantation, pregnancy and abortion rate of IVF and ICSI showed no significant difference among three groups (p?>?0.05).

Conclusion: ICSI cannot improve clinical outcomes of the patients with teratozoospermia in the ultra-short term GnRH-a protocol.     

Endometriosis and IVF: are agonists really better? Analysis of 1180 cycles with the propensity score matching

Abstract

Objective: To compare the outcomes of patients with confirmed endometriosis undergoing in vitro fertilization (IVF)-embryo transfer (ET) treated with either gonadotropin-releasing hormone agonist (GnRHa) or gonadotropin-releasing hormone antagonist (GnRHant) using the propensity score (PS) matching.

Design: Observational, retrospective analysis from January 2000 to December 2010.

Setting: Private tertiary fertility clinic.

Patient(s): Patients with endometriosis confirmed by ultrasound or surgery (American Fertility Society; AFS grades I–IV) that underwent an IVF-ET, stimulated with standard controlled ovarian hyperstimulation (COH) and GnRHa or GnRHant.

Intervention(s): A PS was assigned to all patients, which calculates the conditional probability of receiving a certain treatment; a higher PS (1) meant a higher probability of receiving treatment with GnRHa, and a lower PS (0) meant a higher probability of receiving GnRHant. The PS was calculated with a logistic regression model adjusted specifically for age, follicle stimulating hormone, antral follicle count and previous IVF cycles. All patients were divided into three groups according to their PS.

Main outcome measure(s): pregnancy rate (PR) per cycle.

Results: 1180 patients were analyzed. Raw PR per cycle was 41.8% and 23.4%, and PR per ET was 44.3 and 27%, respectively. PR per cycle: 41.9 versus 30% in group A; in group B, 39.7% versus 36.4% and in group C, 15.4% versus 18.9%. The overall odds ratio for PR adjusted by PS was 1.10 [0.58–2.19].

Conclusions: After matching patients by PS, PR after COH with either GnRHa or GnRHant may be equally effective.     

Low dose gonadotropin-releasing hormone agonist treatments with early discontinuation for controlled ovarian hyperstimulation in an<Emphasis Type="Italic">in vitro</Emphasis> fertilization program

Aim:  The purpose of the present study was to investigate the applicability of a protocol for controlled ovarian hyperstimulation (COH) featuring early discontinuation of low dose gonadotropin-releasing hormone agonist (GnRHa) for ovulation induction for in vitro fertilization (IVF).
Methods:  Four hundred and eighty-seven women undergoing 555 IVF cycles were recruited into the study. Controlled ovarian hyperstimulation was achieved by using either a short protocol of low dose GnRHa (for 5 days only; groups 1 and 2) or a modified long protocol with early discontinuation of GnRHa (groups 3 and 4). Groups 1 and 3 received urinary follicle-stimulating hormone (FSH) and groups 2 and 4 received recombinant FSH. Oocyte retrieval was performed 34 to 36 h after human chorionic gonadotropin (hCG) injection, followed by embryo transfer 3 days later.
Results:  Luteinizing hormone (LH) levels on the hCG injection day were lower with the modified long protocol (groups 3 and 4) than with the short 5-day treatment (groups 1 and 2). There were higher LH levels in group 1 than in groups 2, 3 and 4, resulting in a worse fertilization rate and clinical pregnancy rate. There were no statistically significant differences between groups 2, 3 and 4 in the rates of fertilization, clinical pregnancy and delivery. A higher estradiol (E₂) level in group 3 than in groups 1, 2 and 4 resulted in a worse implantation rate.
Conclusion:  Early cessation of GnRHa may not induce a premature LH surge in controlled ovarian hyperstimulation, while a low dose also offers a useful alternative to a long protocol of IVF. Ovarian stimulation with recombinant follicle-stimulating hormone (rFSH) is considered to be favorable in this low dose GnRHa treatment. (Reprod Med Biol 2003; 2 : 25–30)     

减少GnRHa剂量对长方案促排卵卵巢反应性的影响

目的:探讨减少GnRHa剂量对长方案促排卵的卵巢反应性影响。方法:对37例采用长方案进行促排卵且第一周期未妊娠或流产的患者进行自身对照研究,第一个周期GnRHa用量为0.05mg/d,第二个周期GnRHa用量为0.03mg/d。结果:Gn使用天数、Gn用量、受精率第一、第二促排卵周期间无显著性差异(P>0.05)。获卵数、可移植胚胎数第二周期组较第一周期组显著增加(P<0.05)。结论:本研究认为在长方案促排卵过程中减少GnRHa的剂量可以增加获卵数,改善卵巢反应性,增加IVF妊娠率。     

Ovulation induction and luteal support with GnRH agonist in patients at high risk for hyperstimulation syndrome

Abstract

The aim of this study was to compare GnRHa trigger and luteal addition of triptorelin to hCG trigger for final oocyte maturation in women at high risk for OHSS undergoing IVF. A total of 423 patients were divided in two groups both stimulated using antagonist short protocol. Gonadotropins 75–150 UI/day were started on day 2–5, GnRH antagonist was added when the lead follicle was >14?mm and the final trigger was obtained with hCG 250?µg or triptorelin 0.2?mg. The luteal phase was supported with progesterone alone in the hCG group, with progesterone plus triptorelin 0.1 every other day from embryo transfer in the triptorelin group. In the triptorelin group we did neither have to suspend any embryo transfer, nor we have any early clinical OHSS. In the control group, 13 patients were suspended due to symptomatic high risk for OHSS and two patients developed a clinically significant OHSS. No statistically significant difference was observed in terms of clinical and ongoing pregnancy rates and implantation rates. Our results indicate that a protocol including GnRHa as trigger and an intensive luteal phase supported with GnRHa is safer than a standard antagonist protocol using hCG as trigger. It displays similar results, therefore it can be used as the first choice in patients at high risk for OHSS.     

Pituitary suppression with GnRH agonists before ART may be insufficient to treat women with severe adenomyosis

Research questionDoes aromatase inhibitor improve IVF outcomes by reducing local oestrogen production in patients with adenomyosis undergoing long-term gonadotrophin-releasing hormone agonist (GnRHa) treatment?DesignFour patients with severe adenomyosis who failed to improve after long-term treatment (≥3 months) with depot GnRHa received treatment with an aromatase inhibitor for 21 days. Blood oestradiol concentrations were monitored after GnRHa treatment both before and after treatment with an aromatase inhibitor. Women received a transfer of IVF autologous or donor oocytes. Pregnancy and ongoing pregnancy rates were the primary outcomes. Blood oestradiol concentration after treatment with an aromatase inhibitor was a secondary outcome.ResultsPatients with severe adenomyosis presented with hyperestrogenism due to local production from the lesions even after long-term treatment with GnRHa. Treatment with an aromatase inhibitor reduced hyperestrogenism and improved clinical outcomes in adenomyosis patients who have experienced previous embryo transfer failures.ConclusionWomen with severe adenomyosis would benefit from letrozole or a combination of GnRHa plus letrozole before receipt of treatment with assisted reproductive technology. For women with severe adenomyosis, GnRHa treatment alone may be insufficient to suppress oestrogen production by adenomyotic lesions. Thus, it should be mandatory to test for oestradiol concentrations in patients with severe adenomyosis who have received long-term GnRHa treatment. Also, GnRHa may not always be the sole strategy for medical management of adenomyotic lesions. Letrozole is safe and can improve IVF outcomes for patients with adenomyosis.     

Effect of delayed initiation of gonadotropin in luteal long protocol on in vitro fertilization

Abstract

Objective: To evaluate whether delayed initiation of gonadotropin in luteal long protocol affected the outcome of in vitro fertilization (IVF).

Study design: Prospective randomized study at the reproductive centre of a university-based hospital. Eighty-five subfertile women undergoing IVF embryo transfer after a standardized gonadotropin-releasing hormone agonists (GnRHa) long protocol. The patients were randomized into group A (stimulated 3 weeks after GnRHa administration) and group B (stimulated 2 weeks after GnRHa administration), according to the time of gonadotropin initiation after GnRHa-mediated pituitary suppression. The main outcome measures were clinical pregnancy and live birth rates.

Results: There were no significant differences in baseline characteristics such as age, body mass index and basal follicle-stimulating hormone (bFSH) between the two groups. In group B, the days of gonadotropin stimulation were significantly greater than that in group A (p?<?0.05), while the total dose of gonadotropin in group A was comparable to that in group B. Serum luteinizing hormone was lower and follicle-stimulating hormone higher in group A than in group B (p?<?0.05) on initiation day. There were no significant differences in hormone profile measurements between the two groups. Moreover, the clinical pregnancy rate, implantation rate, live birth rate, miscarriage rate and moderate ovarian hyperstimulation syndrome rate were not significantly different between the groups.

Conclusion: Delay of gonadotropin stimulation in a standard long protocol may increase clinical efficiency, without significantly changing clinical outcome.