Minimal stimulation protocol for use with intrauterine insemination in the treatment of infertility

OBJECTIVE: To determine whether minimal stimulation with clomiphene and one injection of 150 IU of human menopausal gonadotrophin (hMG) provides pregnancy rates comparable with those in a conventional full hMG stimulation protocol for infertile patients undergoing intrauterine insemination (IUI). METHODS: A prospective study was carried out at the Infertility Clinic of a teaching institute and tertiary care referral center in Chandigarh, India. Two hundred couples with either unexplained infertility or ovulatory dysfunction cases who ovulated with clomiphene citrate (CC) but failed to conceive were offered ovarian stimulation with CC and hMG along with IUI for 420 cycles. Pregnancy rate, medication and monitoring cost were compared between minimal and conventional stimulation protocols. RESULTS: There was no difference in the couples of the two stimulation protocols regarding their age, duration and type of infertility as well as cause of infertility. Number of ampoules of hMG and monitoring costs were significantly higher in the full hMG stimulation cases whereas pregnancy rate was comparable in both protocols. CONCLUSION: Minimal stimulation appears to be an effective protocol in cases of unexplained infertility undergoing intrauterine insemination. Reduced cost and minimal monitoring is appealing to patients and the clinician.     

Choice of an ovarian stimulation protocol according to the follicular puncture method in an in vitro fertilization programme

In order to ascertain the adequacy of ovarian stimulation protocols with a type of follicular puncture, 126 women undergoing in vitro fertilization received either combination clomiphene/hMG or hMG alone according to a randomized test protocol. Within both groups patients for whom a pelvic examination was required had laparoscopies, while others had transvaginal ultrasonically guided punctures as far as possible. Clomiphene/hMG was more efficient than hMG alone as assessed from the cleavage rate (68% vs. 54%; p less than 0.01) and the pregnancy per attempt rate (16% vs. 5%; p less than 0.05). Laparoscopic punctures were more efficient than ultrasonically guided punctures (mean number of recovered oocytes: 4.8 +/- 2.6 vs. 3 +/- 2.5; p less than 0.001), but slightly better results were achieved by this latter method in ongoing pregnancy per puncture rate (18% vs. 8%; NS). With ultrasonically guided punctures, stimulation by clomiphene/hMG allowed better oocyte recoveries (3.8 +/- 2.5 vs. 2.3 +/- 1.9, p less than 0.05). Such results constitute an argument for preferential use of the clomiphene/hMG stimulation protocol with ultrasonically guided punctures.     

Outcome of in vitro fertilization-embryo transfer according to age in poor responders with elevated baseline serum follicle stimulation hormone using minimal or no gonadotropin stimulation

PURPOSE: To determine whether decreased ovarian reserve or advancing age are more associated with decreased oocyte quality. METHODS: Women with baseline serum follicle stimulating hormone (FSH) > 12 mIU/ml who demonstrated previous poor response to controlled ovarian hyperstimulation (COH) had oocyte retrieval without gonadotropin stimulation in natural cycles or with minimal stimulation (maximum 75 IU gonadotropins) without agonists or antagonists were evaluated following in vitro fertilization-embryo transfer. RESULTS: The ongoing/delivered pregnancy rates were 27.3%, 30.8%, 21.7%, and 0.0%, respectively, with a mean of 1.06 embryos per transfer. The implantation rates were 33.3%, 28.6%, 14.7%, and 6.0%. Approximately half of the retrievals resulted in failed fertilization. CONCLUSION: Using these minimal or no drug COH regimens in a difficult group of women, age was found to be a more adverse infertility factor than elevated serum FSH.     

黄体期长方案控制性卵巢刺激周期体外受精-胚胎移植临床分析

目的探讨黄体期GnRH-a 1.25 mg长方案控制性卵巢刺激周期体外受精-胚胎移植的临床效果。方法回顾性分析在广西妇幼保健院生殖中心实施的137个黄体期GnRH-a 1.25 mg长方案控制性卵巢刺激周期体外受精-胚胎移植（IVF-ET）资料,对比妊娠组与未妊娠组的体外受精情况,并将获卵数≤8设为1组,获卵数9～17个为2组,获卵数≥18个为3组,比较分析三组的卵巢刺激过程的内分泌变化及临床结局。结果妊娠组与未妊娠组对比获卵数差异无统计学意义（P〉0.05）,正常受精率差异有统计学意义（P〈0.05）;按三组不同获卵数分析的结果,三组年龄最小,卵巢反应性高,胚胎冷冻率较1组、2组显著升高（P〈0.05）,但三组单次移植周期妊娠率差异无统计学意义（P〉0.05）,随着获卵数增多,发生卵巢过度刺激综合征的风险明显增高（P〈0.05）。结论黄体期长方案控制性卵巢刺激周期在维持一定的正常受精率的基础上可以获得满意的临床效果。     

A prospective randomized clinical trial comparing 150 IU and 225 IU of recombinant follicle-stimulating hormone (Gonal-F*) in a fixed-dose regimen for controlled ovarian stimulation in in vitro fertilization treatment

OBJECTIVE: To compare fixed daily doses of the recombinant FSH (rFSH) Gonal-F (150 IU vs. 225 IU) for ovarian stimulation in IVF-ET. DESIGN: Single-center prospective, randomized study. Assisted conception unit of a university hospital.One hundred twenty-four women aged 23-41 years participated in the study. Exclusion criteria were as follows: FSH of >10 IU/L, polycystic ovarian syndrome, one ovary or previous ovarian surgery, previous poor response to ovarian stimulation, or ovarian hyperstimulation syndrome (OHSS). INTERVENTION(S): Randomized to commence 150 IU or 225 IU of Gonal-F per day without dose alterations during treatment. MAIN OUTCOME MEASURE(S): Number of oocytes retrieved and total rFSH dose. RESULT(S): More oocytes were retrieved in women aged or=33 years), the number of oocytes retrieved in the two groups were similar. No significant differences were found for fertilization rate, number of embryos formed and cryopreserved, and pregnancy rates between the two groups. The total rFSH dose used was higher in the 225-IU group (2,595.0 +/- 510.0 vs. 1,897.5 +/- 457.5 IU). The cancellation rate due to insufficient ovarian response was higher in the 150-IU group (15.0% vs. 3.3%). All cases of ovarian hyperstimulation syndrome (n = 4) occurred in the 225-IU group. CONCLUSION(S): Two hundred twenty-five IU is more effective than 150 IU in younger women but requires a higher total dose of Gonal-F. The use of 225 IU in older women did not result in a higher oocyte yield, suggesting that 225 IU of rFSH does not compensate for the age-related decline in the number of follicles available for stimulation.     

Minimal stimulation using recombinant follicle-stimulating hormone and a gonadotropin-releasing hormone antagonist in women of advanced age

OBJECTIVE: To determine whether minimal stimulation with short-term application of low-dose recombinant follicle-stimulating hormone (FSH) together with a gonadotropin-releasing hormone (GnRH) antagonist represents a cost-effective treatment regimen for patients with elevated FSH levels, aged 40 and above. DESIGN: Retrospective cohort study. SETTING: Academically affiliated private in vitro fertilization (IVF) program. PATIENT(S): Eighty-five IVF cycles using minimal ovarian stimulation and 85 cycles with a standard long-stimulation protocol, conducted between January 2000 and January 2002, in women aged 40 and above who had slightly increased FSH levels. INTERVENTION(S): Patients on the long protocol underwent standard cycle monitoring and stimulation. In contrast, women with minimal stimulation had transvaginal sonography initiated on day 8 of the menstrual cycle and at a follicle size of 13 mm. We administered 0.25 mg of GnRH antagonist and 75 IU recombinant FSH daily until ovulation induction. MAIN OUTCOME MEASURE(S): Numbers of oocytes, and rates of cancellation and pregnancy. RESULT(S): Minimal stimulation cycles resulted in a clinical pregnancy rate of 8.2% per started cycle and 10% per embryo transfer (ET), whereas the control group yielded a clinical pregnancy rate of 10.6% per started cycle and of 10.7% per ET (not statistically significant). CONCLUSION(S): In women aged 40 and above with abnormal FSH levels, minimal stimulation protocol achieves similar pregnancy rates to a standard protocol, and thus represents a cost-effective alternative.     

A randomised study of GnRH antagonist (cetrorelix) versus agonist (busereline) for controlled ovarian stimulation: effect on safety and efficacy

OBJECTIVE: To assess safety and efficacy of cetrorelix utilisation in controlled ovarian stimulation (COS). STUDY DESIGN: Phase III, randomized, single center study of 131 patients undergoing COS and IVF with or without ICSI, in a University affiliated Hospital. Sixty-six patients were allocated to the protocol with antagonist and 65 to the agonist protocol arm. The Student's t-test, the Mann-Whitney test and the chi-square test were applied as required, using SPSS for Windows with a two-sided 5% significance level. RESULTS: The mean (+/-S.D.) duration of stimulation was 9.5+/-1.7 days in the antagonist group and 10.6+/-2.1 days in the agonist group (P=0.02). The mean (+/-S.D.) duration of suppression was 4.6+/-1.3 days in the antagonist group and 27.3+/-5.2 days in the agonist group (P<0.0001). No significant differences were noted in other outcome measures: amount of rFSH required, estradiol level on hCG day, number of follicles>or=15 mm and endometrial thickness on oocyte retrieval day, number of oocytes retrieved, fertilization rate and number of OHS cases. Clinical pregnancy rates per-attempt and per-transfer were 15.1% and 17.0% in the antagonist group and 16.9% and 20.0% in the agonist group (P=0.79 and 0.71, respectively). CONCLUSIONS: GnRH antagonists are an effective, safe and well tolerated alternative to agonists for COS.     

Optimal pregnancy outcome in a minimal-stimulation in vitro fertilization program

OBJECTIVE: We sought to provide a cost-beneficial approach to in vitro fertilization for infertile patients who could not afford the standard treatment with in vitro fertilization and to determine the optimal level of minimal ovarian stimulation to achieve acceptable pregnancy rates. STUDY DESIGN: We performed a retrospective cohort study of 216 patients who underwent "minimal stimulation" in vitro fertilization between January 1994 and December 1998. During the first half of this study, various minimal ovarian stimulation protocols were performed in our private, free-standing center for in vitro fertilization. More recently, more ovarian stimulation, including a 4-day protocol featuring gonadotropin-releasing hormone agonist flare (ultrashort flare), was used. Clinical pregnancy outcome, multiple gestation, complications, and maternal age were compared between the first and second halves of this study. RESULTS: The average ages of patients in the first half (phase 1) and the second half (phase 2) were similar, 32.4 +/- 0.3 versus 32.6 +/- 0.3 years, respectively. An average of 3.5 oocytes per retrieval was obtained in phase 1 versus 5.9 oocytes in phase 2. Failure to retrieve oocytes occurred in 3% of all cases. The mean number of embryos transferred per patient was 2.0 in phase 1 versus 2.4 in phase 2. In phase 1, 16.1% of patients failed to have viable embryos for transfer, in comparison with 9.7% in phase 2. The overall clinical pregnancy rate per retrieval was 16.9% in phase 1 versus 36. 6% in phase 2. Multiple gestation occurred in 5.0% of clinical pregnancies in phase 1 but increased to 33% in phase 2, with 9 sets of twins and 6 sets of triplets. The implantation rate was 9.3% for phase 1 versus 23.3% for phase 2. The clinical pregnancy rates per retrieval for phase 2 patients were 41.6% in women < or =34 years old and 25.6% for those > or =35 years old. No case of ovarian hyperstimulation syndrome was noted. CONCLUSIONS: Minimal ovarian stimulation in the setting of in vitro fertilization offers a cost-beneficial alternative to standard treatment with in vitro fertilization in infertile patients who are <35 years old and in women <40 years old who have adequate oocyte reserve. More stimulation improves outcome. Minimalstimulation in vitro fertilization provides an alternative for those patients who cannot afford standard in vitro fertilization or who are concerned with exposure to high dosages of fertility medications.     

The administration of glucocorticoids for the prevention of ovarian hyperstimulation syndrome in in vitro fertilization: a prospective randomized study.

OBJECTIVE: To determine if the administration of glucocorticoids reduced the rate of ovarian hyperstimulation syndrome (OHSS) in high-risk patients after ovarian stimulation for in vitro fertilization (IVF). DESIGN: Prospective randomized study. PATIENTS: Thirty-one patients who were stimulated with human menopausal gonadotropin (hMG) after pituitary desensitization by gonadotropin-releasing hormone agonist and who developed greater than 20 follicles greater than 12 mm and/or had a serum estradiol (E2) level of greater than 10,000 pmol/L on the day of administration of human chorionic gonadotropin (hCG). INTERVENTIONS: Patients were randomly divided into two groups. Those who were randomized to receive glucocorticoids (group A) (n = 17) were administered intravenous hydrocortisone, 100 mg, immediately after ultrasound (US)-directed oocyte recovery. Prednisolone, 10 mg three times per day, was given for 5 days starting on the day of oocyte recovery followed by prednisolone 10 mg two times a day for 3 days and 10 mg/d for 2 days. Those in group B (n = 14) did not receive any glucocorticoid treatment. In both groups, luteal support was provided by intramuscular injections of gestone 100 mg/d. RESULTS: The two groups of patients were comparable in terms of age, duration of infertility, and total dose of hMG used. All had polycystic ovaries on US examination. On the day of hCG administration, the mean number of follicles in the two groups were 26.76 +/- 2.49 and 25.93 +/- 1.44 and the serum E2 concentration 13,404 +/- 710 and 13,915 +/- 901 pmol/L, respectively. There were no significant differences in the number of oocytes collected or in the fertilization, cleavage, and implantation rates in the two groups. The pregnancy rates per initiated cycle were 41.18% and 35.71%, respectively. Seven of the 17 patients (41.2%) who received glucocorticoids developed ovarian hyperstimulation syndrome compared with 6 of the 14 patients (42.9%) who did not receive glucocorticoids. CONCLUSIONS: Administrations of glucocorticoids to high risk patients did not reduce the rate of OHSS after ovarian stimulation for IVF.     

卵巢反应低下患者辅助生殖技术促排卵方案的对比分析

目的:通过比较卵巢反应低下(POR)患者在进行辅助生殖技术(ART)治疗中几种促排卵方案的治疗结局,探讨针对POR患者经济有效、个性化的促排卵方案。方法:回顾性分析行体外受精/卵细胞浆内单精子注射(IVF/ICSI)治疗的POR患者共302个周期,按不同促排卵方案分为4组:超短方案组(43个周期),短方案组(30个周期),氯米芬联合尿促性素微刺激方案组(CC+HMG组,62个周期),卵泡期尿促性素联合甲羟孕酮方案组(HMG+MPA组,167个周期)。对4组患者的促排卵情况、周期取消情况及每起始周期的临床结局进行比较。结果:(1)4组患者ART周期中Gn天数、Gn用量、药费、扳机日优势卵泡数、获卵率、性价比比较,差异有统计学意义(P0.05);其中,超短方案组的Gn天数最长,Gn用量最多;短方案组扳机日优势卵泡数最多,完成1次治疗周期的药费最贵,相对取得1个可移植胚胎的性价比最差;CC+HMG组的Gn天数最短、Gn用量最少,但扳机日优势卵泡数最少,获卵率也最低;HMG+MPA组药费最低,获卵率最高,性价比最好。(2)在取消周期方面,4组间因异常受精及未受精、未卵裂、无可移植胚胎、无优质胚胎而取消周期的差异无统计学意义(P0.05)。CC+HMG组及超短方案组的未获卵周期率高于短方案组及HMG+MPA组(P0.05)。(3)4组方案每起始周期的临床妊娠率、着床率比较,差异无统计学意义(P0.05)。HMG+MPA组的流产率低于CC+HMG组(P0.05);HMG+MPA组每起始周期的继续妊娠率高于超短方案组与CC+HMG组(P0.05)。结论:卵泡期HMG+MPA方案可能是POR患者的一种经济的、有效的、有利于患者的促排卵方案。     

高剂量来曲唑在卵巢低反应患者微刺激方案中的临床观察#br#

Objective?To explore the clinical application value of high-dose letrozole in poor ovarian response(POR) patients during mild ovarian stimulation protocols receiving IVF/ICSI. Methods?A retrospective analysis was performed on 102 patients with POR treated with letrozole mild ovarian stimulation in IVF/ICSI at our reproductive Center from January 2016 to December 2018. The high-dose letrozole group (7.5 mg/d×5 d) was the high-dose group (n=50), and the conventional letrozole group (5 mg/d×5 d) was the conventional dose group (n=52). Results?The age and basal FSH of the high-dose group were higher than those of the conventional dose group (P<0.05), and the number of sinus follicles (AFC) in the high-dose group was significantly lower than that in the conventional dose group (P<0.05). The time of use of gonadotropin (Gn) in high dose group was shorter than that in conventional dose group (P<0.05), the daily serum E2 level of human chorionic gonadotropin (hCG) was significantly decreased (P<0.05), the egg number was lower than that in conventional dose group, but the egg MⅡrate was significantly higher than that in conventional dose group (P<0.05). The clinical pregnancy rate and live birth rate per fresh transplant cycle increased in the high-dose group [55.56% vs 50%; 55.56% vs 37.5%], but the difference was not statistically significant compared with the conventional dose group (P>0.05). Conclusion?For POR patients receiving ART, high-dose letrozole with mild ovarian stimulation protocol can improve the clinical pregnancy outcome of POR patients to some extent without obvious adverse reactions, especially for POR patients with poor ovarian reserve, which may benefit from improving oocyte quality and high MII rate suggesting improved follicle quality.     

Efficacy of recombinant human follicle-stimulating hormone in improving oocyte quality in assisted reproductive techniques

OBJECTIVE: To estimate the efficacy of recombinant human follicle-stimulating hormone (rFSH) versus highly purified urinary human FSH (uFSH) in women undergoing controlled ovarian hyperstimulation (COH) for in vitro fertilization and embryo transfer (IVF-ET). STUDY DESIGN: This prospective, randomized, quality of retrieved double-blind study compared uFSH with rFSH in IVF-ET rFSh cycles. A total of 254 cycles from 241 patients who attended the infertility clinic at Samsung Cheil Hospital from January to August 2001 were included in the study. With pituitary desensitization using gonadotropin-releasing hormone agonist and a short protocol, rFSH was administered in 131 cycles; uFSH was administered in 123 cycles. We analyzed ovarian response, oocyte quality, fertilization rate, embryo quality, pregnancy rate and live birth rate in the uFSH and rFSH groups. RESULTS: Total FSH dosage (1322.3 +/- 526.2 vs. 2124.4 +/- 881.9 i.u.) and dosage per retrieved oocyte (90.6 +/- 36.0 vs. 138.0 +/- 57.2 i.u.) were significantly lower in the rFSH group than those in the uFSH group (P < .001). The proportion of good-quality oocytes (grade 1 and 2) was higher in the rFSH group (68.2% vs. 64.8%, P = .024). Moreover, the proportion of atretic oocytes (grade 5) was lower in the rFSH group (7.5% vs. 10.3%, P = .002). The fertilization rate, quality of transferred embryos, clinical pregnancy rate and live birth rate were not significantly differ between the 2 groups. CONCLUSION: In women undergoing COH, rFSH revealed more efficient ovarian response and better quality of oocytes than did uFSH.     

Recombinant gonadotrophins associated with GnRH antagonist (cetrorelix) in ovarian stimulation for ICSI: comparison of r-FSH alone and in combination with r-LH

OBJECTIVE: The objective was to verify the outcome of intracytoplasmic sperm injection (ICSI) with ovulation induction performed with GnRH antagonists, comparing the use of recombinant follicle-stimulating hormone (r-FSH) alone and in combination with recombinant luteinizing hormone (r-LH) in a prospective and randomized trial. STUDY DESIGN: Forty male-factor infertile normo-ovulatory patients undergoing ovarian stimulation for ICSI took part in the study. After initiating ovarian stimulation with only r-FSH, all patients were treated with GnRH antagonist (cetrorelix). When beginning cetrorelix administration, the patients were randomized into two groups: in group I, 20 patients continued to receive r-FSH alone and in group II, 20 patients received combined r-FSH and r-LH. The number of metaphase II oocytes, estradiol concentration at the time of hCG administration, fertilization rate, grade 1 embryo rate, pregnancy rate per cycle, and implantation rate were measured. Results are expressed as mean+/-S.D. RESULTS: In group I, the women's age was 32.3+/-2.30 years, and FSH concentration was 7.8+/-1.7 IU/ml. In group II, the women's age was 32.2+/-2.46 years and FSH concentration was 7.5+/-1.7 IU/ml. The number of oocytes retrieved was 9.6+/-2.9 and the number of metaphase II oocytes was 6.7+/-2.2 in group I. In group II the number of retrieved oocytes were 9.9+/-2.6 and the number of metaphase II oocytes 6.9+/-2.1 (p>0.05). Estradiol concentration at the time of hCG was 4.6+/-1.8 nm/l in group I and 6.7+/-2.0 nm/l in group II (p<0.01). Fertilization rate was 73.0% in group I versus 78.2% in group II. In group I, we obtained 53.9% of grade 1 embryos versus 54.4% in group II (p>0.05). Pregnancy and implantation rates in group I were 30.0 and 16.7%, respectively and in group II 35.0 and 20.4%, respectively (p>0.05). CONCLUSIONS: The use of recombinant LH in addition to recombinant FSH may prevent a decrease in estradiol after GnRH antagonist administration, but does not influence positively the outcome of oocyte number, maturation, embryo quality, fertilization rate, pregnancy rate per cycle, and implantation rate.     

Follitropin-alpha versus human menopausal gonadotropin in an in vitro fertilization program

OBJECTIVE: To compare the efficacy of recombinant FSH and urinary-derived hMG for ovarian stimulation during IVF. DESIGN: Retrospective analysis of data from IVF cycles conducted over 15 months. SETTING: University hospital IVF unit. PATIENT(S): Three hundred twenty-four women undergoing their first to sixth IVF cycle. INTERVENTION(S): After pituitary down-regulation, patients received recombinant FSH or hMG, according to personal choice. After hCG administration, patients underwent oocyte retrieval, oocyte fertilization, and embryo transfer. MAIN OUTCOME MEASURE(S): Implantation rate and clinical ongoing pregnancy rate per oocyte retrieval. RESULT(S): Patients who chose recombinant FSH were slightly younger than those who chose hMG (34.1 vs. 35.1 years, respectively). Although more embryos were transferred in the hMG group (3.6 vs. 3.2), the ongoing pregnancy and implantation rates were significantly higher in the recombinant FSH group (ongoing pregnancy rate, 50.0% vs. 36.2%). CONCLUSION(S): Recombinant FSH is more effective than hMG for ovarian stimulation in IVF cycles. This increased efficacy, which is achieved with fewer ampoules, is likely to offset the higher acquisition costs of recombinant FSH.     

体外受精周期卵巢储备功能正常采用激动剂长方案与拮抗剂方案促排卵的临床结局比较

目的:探讨卵巢储备功能正常者采用激动剂长方案和拮抗剂方案促排卵对体外受精周期妊娠结局的影响。方法:回顾性分析卵巢储备功能正常者进行体外受精-胚胎移植(IVF-ET)的265个周期。根据促排卵方案不同将其分为:激动剂长方案促排卵组(长方案组,157个周期),拮抗剂方案组(拮抗剂组,108个周期)。结果:患者的年龄、不孕年限、体质量指数(BMI)、基础性激素水平等一般情况组间均无统计学差异(P>0.05)。hCG注射日直径14 mm以上的卵泡数、hCG注射日E2水平、平均移植胚胎数及胚胎质量、受精率、生化妊娠率、早期流产率等组间均亦无统计学差异(P>0.05);但获卵数(12.6±4.6 vs 10.8±4.6)、可用胚胎数(5.0±3.0 vs 4.2±2.7)、胚胎种植率(29.87%vs 20.98%)、临床妊娠率(42.76%vs 28.70%)长方案组明显高于拮抗剂组,差异有统计学意义(P<0.05)。结论:卵巢储备功能正常者拮抗剂促排卵,其胚胎种植率、临床妊娠率明显低于长方案组。     

Comparison of stimulation with clomiphene citrate in combination with recombinant follicle-stimulating hormone and recombinant luteinizing hormone to stimulation with a gonadotropin-releasing hormone agonist protocol: a prospective,randomized study

OBJECTIVE: To compare IVF-ET outcome with a new stimulation protocol using clomiphene citrate (CC) with recombinant FSH and LH to stimulation with the standard long GnRH-a protocol. DESIGN: Prospective randomized study. SETTING: Outpatient infertility clinic in Vienna, Austria. PATIENT(S): Two hundred ninety-four infertile women undergoing IVF-ET; 154 IVF cycles stimulated with CC + recombinant FSH + recombinant LH (group A) and 140 cycles with long GnRH-a suppression + recombinant FSH (group B). INTERVENTION(S): Controlled ovarian hyperstimulation, egg retrieval, and ET. MAIN OUTCOME MEASURE(S): Cycle parameters (number of oocytes, fertilization, number of embryos) and outcome (pregnancy rate, cancellation rate, ovarian hyperstimulation syndrome [OHSS]). RESULT(S): Pregnancy rate per ET was 42.9% (implantation rate, 21.3%) in group A and 36.6% (17.4%) in group B. Cancellation rates were similar. The OHSS occurred in four cases (3%) in group A and 12 cases (10%) in group B. CONCLUSION(S): Stimulation with CC + recombinant FSH + recombinant LH leads to comparable pregnancy rates vs. the long protocol. With this new stimulation, less gonadotropins are used and there is less need for monitoring (lower cost for patient and clinic). The risk of OHSS is reduced as well. Therefore, this protocol should be regarded as the first-line treatment.     

Comparison of Clinical Outcome and Costs with CC + Gonadotropins and GnRHa + Gonadotropins During IVF/ICSI Cycles

OBJECTIVE: To compare clinical outcome and costs of CC + gonadotropins with GnRHa + gonadotropins during IVF/ICSI cycles. MATERIALS AND METHODS: Clinical outcome and expenses of 382 CC + gonadotropin and 964 GnRHa + gonadotropin cycles were compared. Medication costs were calculated on the basis of the mean number of ampoules and the proportion of various gonadotropins. Costs per clinical pregnancy were calculated on the basis of expenses and clinical pregnancy rates. RESULTS: Women in the CC + gonadotropin group were younger, and had fewer follicles, oocytes, embryos, and embryos transferred. Clinical pregnancy rates were higher in the GnRHa group (35.9 % vs 26.2%, p < 0.001). More ampoules of gonadotropins were used in the GnRHa group (24.0 +/- 0.3 vs 20.0 +/- 0.5, p < 0.001). Medication costs per cycle were higher in the GnRHa group (US dollars 357 vs 248). Expenses per pregnancy however were lower in the GnRHa group (USdollars 4197 vs 5335 with IVF; USdollars 5590 vs 7244 with ICSI). When different age subgroups with similar baseline characteristics and stimulation parameters were compared, pregnancy rates were significantly higher in the GnRHa groups. Medication cost per cycle was higher in the GnRHa subgroups, and the expense per pregnancy was lower with GnRHa protocol. CONCLUSIONS: Cost per cycle is higher with GnRHa + gonadotropin. However, because of the better performance of the GnRHa + gonadotropin stimulation, the cumulative costs are reduced by the time a clinical pregnancy is achieved.     

微刺激全部胚胎冷冻方案在常规体外受精-胚胎移植失败的卵巢低反应患者中的应用

目的探讨微刺激全部胚胎冷冻方案在常规体外受精/卵胞质内单精子显微注射-胚胎移植(IVF/ICSI-ET)方案失败的卵巢低反应(POR)患者中的应用价值。方法对196例IVF/ICSI-ET应用常规促排卵方案因POR放弃周期或移植失败后改用微刺激方案的402个周期进行回顾性分析,比较前、后2次不同促排卵方案的临床和实验室指标。结果 402个微刺激周期中32个周期取消,周期取消率为7.96%,370个周期获得卵母细胞,平均获卵数(2.2±1.5)个,共233个周期有胚胎冷冻,胚胎冷冻率为57.96%,共194个周期进行了ET,临床妊娠74例,早期自然流产6例,起始周期累积妊娠率为37.75%(74/196),冻融胚胎移植(FET)周期临床妊娠率为38.14%(74/194),其中≤37岁组FET周期的临床妊娠率(50.89%)明显高于37岁组(20.73%)(P0.05)。微刺激方案的临床和实验室指标均显著优于常规长方案。结论微刺激全部胚胎冷冻方案对常规方案IVF/ICSI-ET治疗失败的POR患者具有疗程短、刺激剂量小,获卵率高、可利用胚胎率高、周期取消率低等特点,对于该类患者再次助孕可考虑微刺激方案。     

Factors influencing pregnancy rates with a combined clomiphene citrate/gonadotropin protocol for non-assisted reproductive technology fertility treatment

OBJECTIVE: To determine the effectiveness of a combined clomiphene citrate/gonadotropin protocol in a general infertility population and to evaluate factors influencing pregnancy rates obtained with this protocol. DESIGN: A retrospective chart review. SETTING; University-based infertility clinic. PATIENT(S): Two hundred forty-eight patients undergoing 658 cycles of minimal stimulation (MS) protocol from 1996-2000. INTERVENTION(S): Patients underwent treatment with clomiphene citrate and gonadotropin, often followed by intrauterine insemination. MAIN OUTCOME MEASURE(S): Clinical pregnancy rates. RESULT(S): Overall, the clinical pregnancy rate was 7.1% per cycle (n = 248 patients and 658 cycles). The age range of the patients was 24-47 years (mean +/- SD = 36.5 +/- 4.9) with 8.7% noted to have ovulatory dysfunction. Pregnancy rates varied significantly (P<.05) with patient age (9.3% in women <40 years vs. 2.4% in women > or =40), duration of infertility (9.0% in women with < or =3 years of infertility vs. 2.2% in women with >3 years of infertility) and number of follicles produced during stimulation (9.1% in women with > or =3 follicles vs. 4.6% in women with <3 follicles). CONCLUSION(S): The effectiveness of the MS protocol in a general infertility population with a predominantly ovulatory status is much less than that previously reported in a younger patient population with a significant rate of ovulatory dysfunction. This protocol does not appear to lead to pregnancy rates higher than that reported for clomiphene citrate/intrauterine insemination (IUI) cycles. The clinical pregnancy rates using a minimal stimulation protocol are particularly compromised in women over 40, those with a longer duration of infertility or those who produce few follicles during stimulation.     

Menotropin stimulation after prolonged gonadotropin releasing hormone agonist pretreatment for in vitro fertilization in patients with endometriosis

Two protocols were scheduled for in vitro fertilization and embryo transfer (IVF-ET) in patients with various stages of endometriosis who were resistant to conventional therapies. In the ultralong protocol (21 patients), gonadotropin releasing hormone agonist (Gn-RHa) was administered for at least 60 days prior to ovarian stimulation along with menotropin until human chorionic gonadotropin was injected. In the long protocol (11 patients), Gn-RHa was started at the midluteal phase and exogenous gonadotropin was commenced between the third and the seventh day of the menstrual cycle after pituitary suppression. The estradiol response and the number of retrieved oocytes, fertilized oocytes, cleaved oocytes, and transferred embryos were similar in both groups but the clinical pregnancy rate per transfer was superior in the ultralong protocol (67 vs 27%). The miscarriage rate was 14% (2/14) in the ultralong protocol. Prolonged Gn-RHa suppression of ovarian function before superovulation may overcome some causes of infertility in patients with endometriosis.