依据扳机日血清E2值制定HCG剂量对ICSI结局的影响

目的 探讨依据扳机日血清E2值制定HCG剂量对卵胞浆内单精子注射（ICSI）促排卵结局的影响。方法 前瞻性分析2012年1－12月在上海瑞金医院生殖中心行ICSI助孕依据HCG日血清E2值制定不同HCG扳机剂量的117名患者的促排卵结局。HCG扳机剂量制定原则：E2值≤16 515 pmol/L为7000 IU、E2值介于16 516～23 854 pmol/L为5000 IU、E2值≥23 855 pmol/L为3000 IU。结果 3组MⅡ率、受精率的差异无统计学意义。7000 IU组卵裂率低于5000 IU组（96.43% vs. 99.62%）,差异有统计学意义（P<0.05）,7000 IU组可用胚胎率高于3000 IU组和5000 IU组（65.43% vs.55.69%和57.74%）,差异有统计学意义（P<0.05）。5000 IU组发生1例中度OHSS。3组新鲜移植周期的平均移植胚胎数、临床妊娠率和胚胎着床率的差异无统计学意义。结论 依据HCG日E2值制定HCG扳机剂量不影响卵母细胞成熟率和妊娠率,即高E2值予以低剂量HCG,低E2值予以高剂量HCG的原则是可行的。     

The HCG ratio as a predictor of pregnancy outcome in assisted conception cycles

ObjectiveTo determine whether the HCG ratio can be used to predict pregnancy viability in patients undergoing IVF/ICSI treatment.Design and settingsThis was a prospective observational study conducted in a private assisted conception unit.Subjects and methodsThe patients recruited had one either a long luteal agonist protocol, a short agonist protocol, or an antagonist protocol. All patients had a maximum of three embryos transferred per cycle. Pregnancy detection was by routine serum HCG measurement on day 14 after oocyte retrieval (HCG 0) followed by another HCG sample 48h later (HCG 48). Patients with an initial positive HCG had a transvaginal ultrasound 14days later to determine viability.ResultsThree hundred and twenty patients were included in the study. We used receiver operating characteristics (ROC) analysis to predict the ability of HCG measured at 14days (HCG 0), HCG measured at 16days (HCG 48) after oocyte retrieval as well as the HCG ratio (HCG 48/HCG 0) to predict pregnancy viability as well as to predict multiple pregnancy. The HCG ratio with an optimal cut-off of 1.82 had a sensitivity of 97.6%, a specificity of 98.2% and an area under the ROC curve of 98% in the prediction of pregnancy viability. In the prediction of multiple pregnancy the HCG ratio had an optimal cut-off of 2.06 with a sensitivity of 94.5% and a specificity of only 35.6% and an area under of only the ROC curve of 64%. However, the HCG 0 with a cut-off value of 118.56mIU/ml (sensitivity 97%, specificity 96.5%) and the HCG 48 with a cut-off value of 258.16mIU/ml (sensitivity 97.2%, specificity 99.4%) were shown to be accurate in predicting a viable intrauterine multiple pregnancy with an area under the ROC curve of 97% and 99%, respectively.ConclusionThe HCG ratio with a cut-off value of 1.82 can be used to predict pregnancy viability in assisted conception cycles. Also HCG measured 14 and 16days after oocyte retrieval with a cut-off value of 118.56mIU/ml and 258mIU/ml can be used to predict viable multiple pregnancy.     

Fertilization in vitro of cumulus-enclosed mouse oocytes: effect of timing of the ovulatory HCG injection

Human chorionic gonadotropin (HCG) may be injected to time ovulation and plan oocyte retrieval for clinical in vitro fertilization (IVF). Neither clinical nor experimental data on effects of subtle alterations in timing of the HCG injection on oocyte fertilizability in vitro were available. We induced follicular development in immature hybrid mice with an injection (4 IU) of pregnant mare serum gonadotropin (PMSG). In the first series of experiments, HCG was given 42, 46 or 50 hours later. We collected cumulus-enclosed, oviducal oocytes for IVF using capacitated mouse sperm 13 hours after the last HCG injection. The fertilization incidence (mean, three experiments) fell as the PMSG-HCG interval was reduced (50 hours, 64%; 46 hours, 40%; 42 hours 24%), but this could be explained by a corresponding increase in spontaneous oocyte activation caused by prolonging the HCG-oocyte collection interval. In the second series of experiments, the latter was fixed at 13 hours; the PMSG interval was altered by staggering the initial PMSG injection. No spontaneous activation occurred, but oocytes collected after "early" HCG injection still showed significantly lower fertilization incidences (42 hours, 36%; 46 hours, 46%) compared with the 50-hour injection (66%). The possible clinical implication of this finding is discussed.     

GnRH agonist versus recombinant HCG in an oocyte donation programme: a randomized,prospective, controlled,assessor-blind study

The use of gonadotrophin-releasing hormone (GnRH) agonists for triggering ovulation remains controversial. The primary objective of this study was to evaluate the incidence of ovarian hyperstimulation syndrome (OHSS) following GnRH agonist versus recombinant human chorionic gonadotrophin (HCG) as methods for triggering ovulation. A second aim was to compare the clinical outcome and embryo quality according to the two procedures. The cycle characteristics of 100 oocyte donors undergoing ovarian stimulation and IVF outcomes of their 100 oocyte recipients were analysed. Donors were prospectively randomized into two groups on the last day of ovarian stimulation: Group I received a single bolus of 0.2 mg of triptorelin and Group II received 250 μg of recombinant HCG. No differences were observed in the number of oocytes retrieved or in the proportion of metaphase II oocytes between the groups. The OHSS rate was higher in donors that received recombinant HCG (P = 0.003). Moreover, there was no significant difference between IVF parameters and outcome in the two groups. In conclusion, a GnRH agonist effectively triggers the final oocyte maturation in oocyte donors without negatively affecting implantation, pregnancy or miscarriage rates. Moreover, this regime effectively eliminates the risk of OHSS in this group of women.     

Effect of gonadotrophin priming on in-vitro maturation of oocytes collected from women at risk of OHSS

This study examined the effects of human menopausal gonadotrophin (HMG) or human chorionic gonadotrophin (HCG) priming on cumulus-oocyte complex (COC) morphology, oocyte maturation and embryo development in patients undergoing in-vitro maturation (IVM) cycles. The patients were primed with nothing (group 1), low-dose HMG (group 2) or 10,000 IU HCG (group 3) before oocyte retrieval. COC with dispersed cumulus cell appearance was only observed in group 3. In addition, 11% of metaphase II stage oocytes at the time of retrieval were collected from group 3. Oocyte maturation in vitro in group 3 was faster than that in groups 1 and 2. The blastocyst development rate of residual embryos after embryo transfer in group 3 was significantly higher than that of groups 1 and 2 (P < 0.05). These results suggest that HCG priming may stimulate the COC, promote oocyte maturation, and improve developmental competence in IVM cycles.     

GnRH agonist trigger and ovarian hyperstimulation syndrome: relook at ‘freeze-all strategy’

A case is reported of early onset ovarian hyperstimulation syndrome (OHSS) after gonadotrophin-releasing hormone agonist (GnRHa) trigger for final oocyte maturation in a GnRH antagonist protocol. The use of GnRHa in place of HCG as a trigger for final oocyte maturation in an antagonist IVF cycle has been proposed as a method for preventing OHSS in predicted high-responders. This approach, however, did not prevent the occurrence of OHSS in our case despite a freeze-all strategy. To the best of our knowledge, this is a possible index case of severe OHSS with GnRHa trigger for oocyte maturation without any luteal HCG rescue for a high responder, despite IVF cycle segmentation.     

血清性激素含量与体外受精-胚胎移植结局的关系分析

目的 探讨在控制性超排卵中血清性激素变化与妊娠结局的关系。方法 随机选择兰州大学第一医院辅助生殖医学中心2003—2004已接受试管婴儿技术治疗，采用黄体期长方案进行控制性超排卵临床妊娠病例147例，未妊娠140例，分析比较组间各项观察指标。结果 两组间患者降调节时间、促性腺激素（Gn）总量、募集卵泡数、获卵数、MII卵数差异均有显著性（P〈0．05），HCG注射日血清孕酮（P）值、血清雌二醇／孕酮（E2／P）比值差异有显著性（P〈0．05）；促性腺激素释放激素激动剂（GnRH—a，达菲林）用量、Gn天数差异无显著性（P〉0．05），降调节后血清黄体生成素（LH）、HCG注射日血清E2、取卵日血清E2、胚胎移植日血清催乳激素（PRL）水平差异无显著性（P〉0、05）。结论 在控制性超排卵治疗中，观察调控血清性激素含量至关重要。HCG注射日血清P值、E2／P比值是预测助孕结局的重要指标，血清E2／P值在1．32—6．11，血清P值在0．637—1.645μg/L时，临床妊娠率增加。     

血清β-HCG水平与人早期胚胎发育的关系

目的:分析HCG日注射剂量不同和12h后血β-HCG水平的差异,探讨其对早期胚胎发育的影响。方法:回顾分析2008年10月~2009年4月721个胚胎移植周期注射HCG后12h的血β-HCG水平。结果:按HCG日注射10000IU、8500IU和6500IU分组,随着HCG注射剂量降低,血β-HCG水平随之降低,差异有统计学意义。获卵数,成熟卵母细胞(MⅡ)率均呈降低趋势,IVF中6500IU组受精率显著低于其它两组(P0.05),ICSI中各组没有显著差异;按注射HCG后12h血β-HCG值分组,IVF-ET和ICSI中,患者年龄、不孕年限、使用Gn天数和支数均无显著差异。β-HCG值100 mIU/ml组的体重指数最高,200 mIU/ml组最低,3组差异有有统计学意义(P0.05)。结论:HCG对卵子的最后成熟很关键,血β-HCG水平可能对胚胎质量没有显著影响,仅影响获卵数和MⅡ率。临床上对于体重指数较高的患者可适当增加HCG剂量,强调治疗方案个体化。     

体外受精-胚胎移植周期中注射绒毛膜促性腺激素日性激素水平与妊娠率的关系

目的：探讨在体外受精－胚胎移植（IVF－ET）周期中注射绒毛膜促性腺激素（HCG）日性激素水平与妊娠率的关系。方法：对71个常规IVE－ET和卵母细胞单精子显微注射（ICSI）周期中注射HCG日的性激素水平进行测定。结果：促黄体生成素（LH）普遍受抑制，与临床妊娠无关；孕酮（P）＜2．86nmol/L时妊娠率较高，雌二醇（E2）（每卵子）513．8－770．7pmol/L时妊娠率高于其它两组。结论：在IVF－ET和ICSI周期中，注射HCG日的P值和E2（每卵子）水平是预测妊娠成功率的一个比较好的指标，当两者联合应用时，可提高预测的准确率。     

Recurrent Empty Follicle Syndrome

We report a case of a recurrent empty follicle syndrome. The patient was admitted to our intracytoplasmic injection program because of her partner's azoospermia. Ovarian stimulation was accomplished using gonadotrophin therapy after treatment with oral contraceptive pills followed by gonadotrophin-releasing hormone agonist. Thirty-six hours after the administration of HCG (human chorionic gonadotrophins), transvaginal oocyte retrieval yielded no oocytes despite the aspiration and flushing of all available follicles. Two years later, a second treatment cycle was started using the same pituitary desensitisation and ovarian stimulation regimens. HCG from a different batch with respect to that used in the first treatment cycle was administered. Aspiration and repeated flushing of all follicles of one ovary failed to yield any identifiable oocyte. The -HCG and progesterone serum concentrations on the day of retrieval were 181 mIU/mL and 3.79 ng/mL, respectively. New oocyte retrieval was planned 6 h after the first attempt for aspiration of follicles. Again, no ova were obtained at this second trial despite the aspiration of the all follicles. As to our knowledge this is the first report of recurrent EFS (empty follicle syndrome) and managed without repeating the HCG injection on the day of unsuccessful oocyte retrieval.     

Complications related to ovarian stimulation and oocyte retrieval in 4052 oocyte donor cycles

A retrospective study was conducted in a private infertility centre to evaluate the rate of complications in a large oocyte donation programme. A total of 4052 oocyte retrievals were performed between January 2001 and October 2007. Altogether, 1238 cycles (30.6%) were stimulated with the use of gonadotrophin-releasing hormone (GnRH) agonists and in 2814 cycles (69.4%) the GnRH antagonist protocol was used. The GnRH antagonist treated cycles were triggered with human chorionic gonadotrophin (HCG) or a GnRH agonist in 1295 and 1519 cycles, respectively. Complications related to oocyte retrieval occurred in 17 patients (0.42%) (intra-abdominal bleeding: n = 14, severe pain: n = 2, ovarian torsion: n = 1). Fourteen of these were hospitalized (0.35%) and six donors (0.15%) required surgical intervention. Pelvic infections, injury to pelvic structures or anaesthesiological complications were not observed in this series. Moderate/severe ovarian hyperstimulation syndrome (OHSS) occurred in 22 donors; 11 required hospital admission and 11 were managed on an outpatient basis. All cases were related to HCG triggering (0.87%). Serious complications related to oocyte retrieval occurred at a low rate in healthy young donors. The risk of OHSS can be substantially reduced by specific stimulation protocols, which include GnRH agonist triggering. Prospective oocyte donors should be adequately counselled about the risks related to egg donation.     

Luteal phase oestradiol suppression by letrozole: a pilot study in oocyte donors

This prospective randomized controlled pilot study was conducted in a tertiary referral university hospital to evaluate whether the administration of letrozole in the luteal phase of stimulated IVF cycles, through a decrease in oestradiol, could alter the suppressed LH levels in the luteal phase. Following oocyte retrieval, six oocyte donors aged < or = 36 years were randomized to receive either 5 mg letrozole (n = 3) or placebo (n = 3). On days 4, 7 and 10 after human chorionic gonadotrophin (HCG) administration, oestradiol levels of the letrozole group were significantly lower compared with the placebo group (P = 0.008, P =0.005 and P =0.004, respectively). LH and progesterone values were comparable between both groups at all time points measured. This study demonstrates that the addition of 5 mg of letrozole in the luteal phase of stimulated donor IVF cycles significantly alters the oestradiol levels on days 4, 7 and 10 after HCG administration for final oocyte maturation. The progesterone and LH profiles of patients treated with letrozole during the same period were not altered compared with the placebo group.     

Similar outcome for cryopreserved embryo transfer following GnRH-antagonist/GnRH-agonist, GnRH-antagonist/HCG or long protocol ovarian stimulation

The pregnancy rates after triggering of final oocyte maturation with gonadotrophin-releasing hormone (GnRH) agonist in GnRH-antagonist ovarian stimulation protocols are lower than those following triggering with human chorionic gonadotrophin (HCG). Furthermore, lower pregnancy rates following GnRH-antagonist protocols compared with long GnRH-agonist protocols have been reported. The differences might be due to an impact on oocyte number and quality or on the endometrium. If any stimulation protocol had a negative impact on oocyte quality, then further evidence of this effect would be observed following frozen-thawed embryo transfer originating from that stimulation cycle. The outcome of frozen-thawed embryo transfer was retrospectively analysed using the long protocol with triptorelin depot 3.75 mg (n = 215) or 0.1 mg/day (n = 83), or GnRH-antagonist protocol with either HCG (n = 69) or GnRH-agonist (n = 25) for final oocyte maturation. The outcomes measured were implantation rate, clinical pregnancy rate, ongoing pregnancy rate and embryo survival rate. All outcomes were similar in the four groups. It is concluded that the potential for frozen-thawed embryos to implant and develop following transfer is independent of the GnRH-analogue and the final oocyte maturation protocol used in the collection cycle. Lower IVF embryo transfer success using GnRH-antagonist/GnRH-agonist protocol does not appear to be related to an adverse effect on oocyte quality.     

促排卵中人绒毛膜促性腺激素扳机时机与药物选择

人绒毛膜促性腺激素（HCG）扳机目的在于促进卵母细胞最后成熟与排卵,此为促排卵中的关键点之一,并与治疗结局密切相关。促排卵周期中HCG的扳机时机主要依赖于对卵泡径线、血中雌孕激素水平和子宫内膜情况等进行综合分析、判断来确定。HCG扳机的药物有HCG制剂和促性腺激素释放激素激动剂（GnRH-a）两种,针对患者和促排卵方案合理选择不同的药物扳机排卵,其对改善助孕结局和降低促排卵并发症有益。     

Unsuccessful oocyte retrieval: technical artefact or genuine 'empty follicle syndrome'?

Unsuccessful oocyte retrieval after apparently successful ovarian stimulation (also referred to as 'empty follicle syndrome') occurs in 1-7% of women undergoing assisted reproductive techniques. A literature review was performed, as individual studies have reached differing conclusions on the aetiology and treatment or management of the phenomenon. The aetiology is not clear, but probably multifactorial, and occurs in natural and stimulated cycles. In many cases, technical problems such as errors in human chorionic gonadotrophin (HCG) administration or defects in HCG batches can be identified, but this is not sufficient to account for all reported cases. The term empty follicle syndrome is inappropriate in cases in which such procedural factors can be identified. In many patients, however, unsuccessful oocyte retrieval appears to be due to an underlying ovarian dysfunction, and some may have a genuine empty follicle syndrome. Appropriate measures, such as monitoring of serum beta-HCG, should be taken to minimize the risk of unsuccessful oocyte retrieval. This review discusses the potential causes of unsuccessful oocyte retrieval, its clinical implications, and potential solutions to this clinical problem.     

LH (as HCG) and FSH surges for final oocyte maturation: sometimes it takes two to tango?

Until now, clinicians have been relying solely on LH activity-dependent triggering of final oocyte maturation and thus taken it for granted that the natural midcycle FSH surge is biologically redundant. However, it is time to question this paradigm. Evidence from clinical studies hint that in a yet-to-be-defined subset of patients, dual LH and FSH surge is advantageous compared with LH-only surge in the form of human chorionic gonadotrophin (HCG) trigger. Dual surge can be triggered by a bolus of gonadotrophin-releasing hormone agonist causing a flare-up of both endogenous LH and FSH, resembling the natural midcycle surge of gonadotrophins. HCG given in parallel secures adequate exposure to LH activity. Further research is needed to characterize the patients in whom FSH surge is needed for proper resumption of the oocyte meiotic process.     

Cumulus cell-oocyte complexes retrieved from antral follicles in IVM cycles: relationship between COCs morphology, gonadotropin priming and clinical outcome

Purpose

To assess retrospectively the developmental potential of different types of cumulus cell-oocyte complexes (COCs) derived from IVM cycles.

Methods

IVM cycles were performed in natural cycles or after HCG, FSH, or FSH/HCG priming. COCs recovered were morphologically characterized in different types: compact (CC) or expanded (EC) cumulus mass but including an immature oocyte, and expanded cumulus mass enclosing a mature oocyte (EC-MII). Embryo developmental competence was investigated analysing exclusively cycles in which all transferred embryos derived from the same COC category.

Results

Fertilization rates did not differ significantly. Significant differences in pregnancy rates (14.5 %, 10.0 % and 27.6 % in the CC, EC, and EC-MII categories, respectively) were observed. Likewise, significant differences in implantation rates (8.9 %, 6.3 % and 19.1 % in the CC, EC, and EC-MII categories, respectively) were found. Overall, priming with FSH/HCG had a beneficial effect on pregnancy and implantation rates, while no priming or HCG alone generated oocytes with poor competence.

Conclusions

In IVM cycles, morphological evaluation at the time of collection can predict the developmental ability of different COCs. FSH/HGC priming has a positive effect on oocyte competence.     

Effects of protein kinase A and C inhibitors on follicular inhibin and activin during ovulation

Ovulation is associated with a rise in activin A and a decline in pro-alpha C, inhibin A and inhibin B secretion. It is believed that the actions of inhibin and activin during human chorionic gonadotrophin (HCG) stimulation are mediated by protein kinase A (PKA) and/or protein kinase C (PKC). Using an in-vitro murine prenatal follicle culture model, the effects of a PKA inhibitor, Rp-cAMP, and a PKC inhibitor, PKIM, on inhibin and activin gene expression, secretion, ovulation and oocyte maturation were studied during HCG stimulation. Both Rp-cAMP (0.1 micromol/l and 1.0 micromol/l) and PKIM (1.0 micromol/l) significantly (P < 0.001) inhibited the action of HCG by suppressing the increase in activin A secretion whilst preventing the decline in pro-alpha C, inhibin A and B. In addition, Rp-cAMP and PKIM were able to significantly (P < 0.05) reduce the rate of HCG-induced ovulation and meiotic resumption, but had no effect on the completion of oocyte maturation. Furthermore, HCG-induced ovulation resulted in the reduction of all three inhibin subunits, but inhibin subunit expression was not affected by Rp-cAMP and PKIM. These results provide evidence supporting a role for PKA and PKC pathways in the signalling mechanism for inhibin and activin action during ovulation and meiotic resumption of the oocyte.     

Embryo transfer and luteal support in natural cycles

Embryo transfer policy and luteal supplementation was reviewed, comparing literature data and the results from the Maribor IVF Centre. A retrospective analysis of 1024 cycles in patients undergoing IVF, intracytoplasmic sperm injection (ICSI) or testicular sperm aspiration in unstimulated cycles was carried out using four different approaches for cycle monitoring. This showed that the most successful protocol for monitoring was administration of human chorionic gonadotrophin (HCG) when serum oestradiol was >0.49 nmol/l and follicle diameter was at least 15 mm. The implantation rate per transferred embryo was higher when a blastocyst was transferred (42.8%) rather than a day-2 embryo (23.5%) in the same monitoring protocol. Analysis of the influence of patient age on the success of oocyte retrieval, oocyte fertilization, embryo transfer rate and delivery rate demonstrates that patient age does not influence the rate of positive oocyte retrieval or fertilization rate as much as it influences pregnancy rate per embryo transfer. The delivery rate per cycle was dramatically influenced by age in patients over 38 years. There is no clear evidence in the literature as to whether luteal phase support is necessary in natural cycles for IVF/ICSI. Comparing the data, a higher pregnancy rate was observed if HCG was administered after embryo transfer.