High Dose Cabergoline in Management of Bilateral Ovarian Hyperstimulation Syndrome: A Case Report

Ovarian hyperstimulation syndrome (OHSS) is an exaggerated response to excess hormones and is also one of the life-threatening iatrogenic complications which is associated with ovulation induction. This syndrome usually occurs in women who receive injectable hormones for the stimulation of egg development in the ovaries. This study describes a rare case of moderate ovarian hyperstimulation syndrome which has been managed and treated with high-dose cabergoline. The patient was diagnosed in the Medical Imaging and Radiation Sciences Department of Kabul University of Medical Sciences and treated in Shahrara Teaching Hospital. A 26-year-old woman was diagnosed with the development of bilateral moderate ovarian hyperstimulation syndrome after receiving clomiphene citrate in dose of 100 mg BID on day 5 of period and Human Chorionic Gonadotropin (HCG) 10,000 units for egg release on day 14 of period. The patient was given a high dose of cabergoline. The dose was adjusted to 1 mg/day for eight days since she was diagnosed with ovarian hyperstimulation syndrome. Consequently, the main outcome of our intervention was complete resolution of OHSS as well as complete recovery of the patient. As a result, it is concluded that the high dose of cabergoline prevents and reduces the occurrence, prolongation, and severity of ovarian hyperstimulation syndrome. However, more assessments through randomized controlled trials regarding the efficacy and safety of cabergoline doses and treatment duration for treatment and preventive purposes are required.

Ovarian Hyperstimulation Syndrome Complicating Spontaneous Molar Pregnancy: A Case Report and Review of the Literature

BACKGROUND

Ovarian hyperstimulation syndrome (OHSS) is traditionally associated with fertility treatments and results in elevated human chorionic gonadotropin (βhCG) levels and fluid shifts to extravascular compartments. Rarely, spontaneous pregnancies with significant βhCG elevations, such as molar pregnancies, can give rise to OHSS.

CASE

A 24-year-old woman was diagnosed as having a molar pregnancy at approximately 12 weeks gestation following spontaneous conception. Her initial βhCG was over 1 million IU/L. There was no evidence of metastatic disease. She underwent an uncomplicated dilation and curettage. Three days later, she presented with chest pain, shortness of breath, and abdominal discomfort. Massively enlarged ovaries were identified with bilateral pleural effusions requiring repeated thoracentesis.

CONCLUSION

This case demonstrates rare sequelae of molar pregnancy. Treatment is mainly supportive, and close observation is required to manage complications. In patients with extremely elevated βhCG levels, clinicians must remain vigilant for signs suggesting OHSS, even following evacuation of the uterus.

Platelet-derived growth factor B restores vascular barrier integrity and diminishes permeability in ovarian hyperstimulation syndrome

Although advances in the prediction and management of ovarian hyperstimulation syndrome (OHSS) have been introduced, complete prevention is not yet possible. Previously, we and other authors have shown that vascular endothelial growth factor, angiopoietins (ANGPTs) and sphingosine-1-phosphate are involved in OHSS etiology. In addition, we have demonstrated that ovarian protein levels of platelet-derived growth factor (PDGF) ligands -B and -D decrease in an OHSS rat model, whilst PDGFR-β and ANGPT2 remain unchanged. In the present work, we investigated the role of PDGF-B in OHSS by evaluating ligand protein levels in follicular fluid (FF) from women at risk of developing OHSS and by using an immature rat model of OHSS. We demonstrated that PDGF-B and PDGF-D are lower in FF from women at risk of developing OHSS compared to control patients (P < 0.05). In the OHSS rat model, PDGF-B (0.5 µg/ovary) administration decreased ovarian weight (P < 0.05), reduced serum progesterone (P < 0.05) and lowered the percentage of cysts (P < 0.05), compared to untreated OHSS rats, but had no effect on the proportion of follicles or corpora lutea (CL). PDGF-B treatment also restored the expression of steroidogenic acute regulatory protein (P < 0.05) and P450 cholesterol side-chain cleavage enzyme (P < 0.01) to control levels. In addition, PDGF-B increased the peri-endothelial cell area in CL and cystic structures, and reduced vascular permeability compared to untreated OHSS ovaries. Lastly, PDGF-B increased the levels of junction proteins claudin-5 (P < 0.05), occludin (P < 0.05) and β-catenin (P < 0.05), while boosting the extracellular deposition of collagen IV surrounding the ovarian vasculature (PP < 0.01), compared to OHSS alone. In conclusion, our findings indicate that PDGF-B could be another crucial mediator in the onset and development of OHSS, which may lead to the development of novel prediction markers and therapeutic strategies.

Nomogram Model to Predict the Probability of Ovarian Hyperstimulation Syndrome in the Treatment of Patients With Polycystic Ovary Syndrome

Objective

The objective of this study was to explore the risk factors of ovarian hyperstimulation syndrome (OHSS) in patients with polycystic ovary syndrome (PCOS) undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) and to establish a nomogram model evaluate the probability of OHSS in PCOS patients.

Methods

We retrospectively analyzed clinical data from 4,351 patients with PCOS receiving IVF/ICSI in our reproductive medical center. The clinical cases were randomly divided into a modeling group (3,231 cases) and a verification group (1,120 cases) according to a ratio of about 3:1. The independent risk factors correlation with the occurrence of OHSS was identified by logistic regression analysis. Based on the selected independent risk factors and correlated regression coefficients, we established a nomogram model to predict the probability of OHSS in PCOS patients, and the predictive accuracy of the model was measured using the area under the receiver operating curve (AUC).

Results

Univariate and multivariate logistic regression analyses showed that FSH (OR, 0.901; 95% CI, 0.847-0.958; P<0.001), AMH (OR, 1.259; 95% CI, 1.206-1.315; P<0.001), E2 value on the day of hCG injection (OR, 1.122; 95% CI, 1.021-1.253; P<0.001), total dosage of Gn used (OR, 1.010; 95% CI, 1.002-1.016; P=0.041), and follicle number on the day of hCG injection (OR, 0.134; 95% CI, 1.020-1.261; P=0.020) are the independent risk factors for OHSS in PCOS patients. The AUC of the modeling group is 0.827 (95% CI, 0.795-0.859), and the AUC of the verification group is 0.757 (95% CI, 0.733-0.782).

Conclusion

The newly established nomogram model has proven to be a novel tool that can effectively, easily, and intuitively predict the probability of OHSS in the patients with PCOS, by which the clinician can set up a better clinical management strategies for conducting a precise personal therapy.

Ischemic Stroke Associated With Ovarian Hyperstimulation Syndrome

BACKGROUND

Ovarian hyperstimulation syndrome (OHSS) is the most serious complication of assisted reproductive technology. Severe OHSS may be accompanied by thromboembolic events, such as pulmonary thromboembolism or acute respiratory distress syndrome. Ischemic stroke may occur in rare cases.

CASE REPORT

We report a 32-year-old woman with a recent medical history of OHSS who presented to the emergency department (ED) with acute onset of impaired consciousness. Her initial Glasgow Coma Scale score was 10 (E3V3M4). History taking and a thorough physical examination were impossible because of the patient's mental status. Additional medical history was obtained with the assistance of the patient's husband. Ischemic stroke was confirmed on diffusion-weighted magnetic resonance imaging performed after a basic examination and confirmation of normal findings on a noncontrast brain computed tomography scan. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although the incidence of cerebral infarction is low in younger patients, emergency physicians treating young women in the ED who have recently undergone fertility treatment or have been diagnosed with OHSS should be aware of the possibility of complications caused by OHSS. Specifically, if these patients complain of traditional or nontraditional neurologic symptoms during an ED visit, stroke should be strongly suspected.. This awareness will reduce the incidence of sequelae through prompt examination and treatment.

A new instrument to personalize ovarian stimulation: results of the CERES study after using a novel gonadotropin - follitropin delta

: Objective: The aim of the study CERES (CzEch REkovelle real life Study) was to gather experience with the use of a novel gonadotrophine, to evaluate the efficacy of follitropin delta in Czech clinical settings and to compare our results with the clinical trial ESTHER-1.

METHODS

Individualized follitropin delta daily dose in µg based on the patient’s anti-Müllerian hormone (AMH) level and body weight (AMH < 15 pmol/ L: 12 µg/ d; AMH > 15 pmol/ L: 0.10–0.19 µg/ kg/ d; max. 2 µg/ d).

RESULTS

A total of 85 women (aged 24-42 years) was included in the study. The average patients age was 32.9 years, the average body weight was 67.8 kg, and the mean level of AMH was 23.2 pmol/&#8202;L. There were initiated 85 controlled ovarian stimulations with follitropin delta and 84 egg collections. Forty patients (47%) had optimal number of retrieved eggs (8-14), 75 patients (88%) had embryotransfer, 10 patients (12%) had no embryo suitable for transfer, 65 patients had single embryo transfer and 10 patients had 2 embryos for transfer. There were reported 37 clinical pregnancies (43.5% cPR - clinical pregnancy rate), 30 live births (35.3% LBR - live birth rate), 3 (3.5%) early moderate ovarian hyperstimulation syndroms (OHSS) and no hospitalization due to the treatment.

CONCLUSION

Individualized ovarian stimulation optimizes ovarian response, maintains treatment efficacy and improves safety by reducing OHSS incidence. The results of the Czech population study are fully comparable with the international, randomized, assessor-blinded trial ESTHER-1.

Current possibilities in the prevention and therapy of ovarian hyperstimulation syndrome

OBJECTIVE

To present current possibilities of the prevention and therapy of ovarian hyperstimulation syndrome (OHSS).

METHODS

Literature and guidelines were researched.

RESULTS

From the view of safety and prevention of OHSS, antagonistic protocol is suitable. Patients with syndrome of polycystic ovaries benefit from the use of metformin or letrozole that can be sufficient to induce ovulation. As a treatment of imminent OHSS, it is recommended to administer 0.5 mg of cabergoline per os daily as well as low molecular weight heparin subcutaneously in prophylactic dose and to maintain sufficient fluid intake. Diuretics are strongly discouraged to use. To maintain intravascular volume, drained ascites can be reintroduced.

CONCLUSION

We present a review of current literature and recommendations.

Oral Vitamin D supplementation impacts gene expression in granulosa cells in women undergoing IVF

STUDY QUESTION

Does oral Vitamin D supplementation alter the hormonal milieu of follicular fluid (FF) and the transcriptomic profile of luteinised granulosa cells (GCs) in women with Vitamin D deficiency undergoing IVF?

SUMMARY ANSWER

A transcriptomic signature relevant to oral Vitamin D supplementation in luteinised GCs was demonstrated, although Vitamin D supplementation did not alter hormone levels in FF.

WHAT IS KNOWN ALREADY

Vitamin D deficiency is linked to lower live birth rates among women undergoing IVF. It is unclear whether Vitamin D elicits a targeted action in reproductive physiology or is a surrogate marker of overall well-being. Several in-vitro studies, but none in vivo, have examined the impact of Vitamin D on the periovulatory follicle, focusing on GCs as a proxy marker of oocyte competence.

STUDY DESIGN, SIZE, DURATION

We present a report of secondary outcomes from the SUNDRO clinical trial, which was launched in 2016 to determine whether Vitamin D supplementation can improve the IVF outcomes of women who are deficient in Vitamin D (<30 ng/ml). FF samples of 145 women who were randomised to receive Vitamin D or placebo from March 2017 to January 2019 were collected. All follicles that were aspirated in our study measured ≥11 mm on the day of hCG trigger. The first cohort of samples was collected from the dominant follicle of each participant and utilised for hormone profiling (n = 50 Vitamin D, n = 45 Placebo). For the second cohort, the follicle aspirates of each participant were pooled to create a single FF sample, which was used for the isolation of GCs for gene expression studies (n = 20 Vitamin D, n = 30 placebo). Six of the samples from the second cohort were used for RNA-sequencing analysis (n = 3 Vitamin D, n = 3 placebo).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Two academic infertility units were involved in the recruitment of the participants, who received a single dose of oral 25-hydroxyvitamin D (600 000 IU) or placebo, 2-12 weeks before oocyte retrieval. Women in both groups were deficient in Vitamin D, aged 18-39 years with a normal BMI (18-25 kg/m2) and <3 previous IVF cycles. The FF was aspirated at the time of oocyte retrieval and stored. Liquid chromatography tandem mass spectrometry was used to measure FF abundance of 25-hydroxyvitamin D, aldosterone, androstenedione, cortisol, cortisone, corticosterone, 11-deoxycorticosterone, 11-deoxycortisol, 21-deoxycortisol, dehydroepiandrosterone, dehydroepiandrosterone sulfate, dihydrotestosterone, oestradiol (E2), 17-OH-hydroxyprogesterone, progesterone (P4) and testosterone. GCs were isolated from pooled FFs and the transcriptome was evaluated by RNA-sequencing and RT-PCR. Ingenuity pathway analysis (IPA) was used to assess the top canonical pathways and upstream regulators mediating the action of Vitamin D.

MAIN RESULTS AND THE ROLE OF CHANCE

At oocyte retrieval, FF concentration of 25-hydroxyvitamin D was 2.8-fold higher (P < 0.001) in the Vitamin D group (39.5 ng/ml; n = 50) compared to placebo (13.8 ng/ml; n = 45) but no other hormonal differences were detected. In the placebo group, but not the Vitamin D group, weak correlations of 25-hydroxyvitamin D concentration with P4 (r = 0.31, P = 0.03) and E2 (r = 0.45, P = 0.002) were observed. RNA-sequencing identified 44 differentially expressed genes in the GCs of patients who received Vitamin D (n = 3) compared to placebo (n = 3). RT-PCR demonstrated upregulation of VDR (vitamin D receptor), GSTA3 (glutathione S-transferase A3) and IL21R (interleukin 21 receptor), and downregulation of P T GS2 (prostaglandin-endoperoxide synthase 2), KLF4 (kruppel-like factor 4), T RP C4 (transient receptor potential cation channel subfamily C member 4), VEGF (vascular endothelial growth factor), RXRB (retinoid X receptor beta) and AGER (advanced glycosylation end-product specific receptor) genes in the Vitamin D (n = 17) versus placebo (n = 27) group. IPA suggested roles of Vitamin D in antioxidant defence.

LIMITATIONS, REASONS FOR CAUTION

Interpretation of the data is influenced by our intervention strategy (2-12 weeks prior to retrieval). As folliculogenesis may last 5-6 months, our protocol can only examine with confidence the impact of Vitamin D on the final stages of follicular growth. Furthermore, we examined the hormonal profile of the dominant follicle only, while the GC data reflect the transcriptome of all (pooled) follicles large enough to be used for IVF. Luteinised GCs from controlled ovarian stimulation were used in this study, which may be functionally distinct from the GCs of developing follicles. Moreover, the sample size for RNA-sequencing analysis was low (n = 3 per group), regardless of validation by RT-PCR that was performed on a larger cohort, introducing complexity to the IPA analysis, which required an input of data with P-adjusted <0.08 instead of <0.05 to be informative.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first in-vivo study to show that Vitamin D supplementation alters gene expression in luteinised GCs. In contrast to some in-vitro evidence, no effect of the intervention on expression of genes encoding steroidogenic enzymes was observed. Unlike other studies, our results suggest that supplementation with Vitamin D is unlikely to directly influence hormone availability in FF. Our findings instead reinforce the hypothesis that Vitamin D could be considered one of the gatekeepers in protecting against an exaggerated response to ovarian stimulation.

STUDY FUNDING/COMPETING INTEREST(S)

The study has been funded by the Italian Ministry of Health (RF-2013-02358757) following peer review in the competitive 'Bando di Ricerca Finalizzata e Giovani Ricercatori 2013' for the clinical trial SUNDRO (EudraCT registration number 2015-004233-27). There are no competing interests.

TRIAL REGISTRATION NUMBER

EudraCT registration number 2015-004233-27.

Prediction of severe ovarian hyperstimulation syndrome in women undergoing in vitro fertilization using estradiol levels, collected ova, and number of follicles

Objective

Our objective was to determine whether estradiol (E2) levels (Day 3 and fold change to Day 10), antral follicle count (AFC), and number of ova collected could predict ovarian hyperstimulation syndrome (OHSS) and culdocentesis intervention.

Methods

We conducted a retrospective review of patient charts between January 2008 and December 2017. OHSS was defined using American Society for Reproductive Medicine criteria. Predictability was evaluated by measuring the area under the receiver operating characteristic curve (AUC).

Results

The cohort included 319 women (166 controls, 153 OHSS, of whom 54 had severe OHSS). The OHSS group had higher E2_Day 3 (249 ± 177 vs. 150 ± 230 ng/L), E2_FoldChange (32.2 ± 29.1 vs. 20.1 ± 23.8), AFC (18.2 ± 9.1 vs. 11.6 ± 8.3), and number of ova collected (21.1 ± 9.0 vs. 10.1 ± 6.5). E2_Day 3 (AUC = 0.76, 95%CI: 0.71–0.82), E2_FoldChange (AUC = 0.71, 95%CI: 0.65–0.77), AFC (AUC = 0.75, 95%CI: 0.70–0.81), and number of ova collected (AUC = 0.85, 95%CI: 0.81–0.89) were predictive for OHSS. All variables were predictive for culdocentesis intervention (E2_Day 3: AUC = 0.63, 95%CI: 0.55–0.70; E2_FoldChange: AUC = 0.63, 95%CI: 0.55–0.71; AFC: AUC = 0.74, 95%CI: 0.68–0.80; number of ova collected: AUC = 0.80, 95%CI: 0.75–0.85).

Conclusions

Day 3 E2 levels and number of ova collected predict patients who could develop OHSS and may require culdocentesis.

The freeze-all strategy versus agonist triggering with low-dose hCG for luteal phase support in IVF/ICSI for high responders: a randomized controlled trial

STUDY QUESTION

Does the freeze-all strategy in high-responders increase pregnancy rates and improve safety outcomes when compared with GnRH agonist triggering followed by low-dose hCG intensified luteal support with a fresh embryo transfer?

SUMMARY ANSWER

Pregnancy rates after either fresh embryo transfer with intensified luteal phase support using low-dose hCG or the freeze-all strategy did not vary significantly; however, moderate-to-severe ovarian hyperstimulation syndrome (OHSS) occurred more frequently in the women who attempted a fresh embryo transfer.

WHAT IS KNOWN ALREADY

Two strategies following GnRH agonist triggering (the freeze-all approach and a fresh embryo transfer attempt using a low-dose of hCG for intensified luteal phase support) are safer alternatives when compared with conventional hCG triggering with similar pregnancy outcomes. However, these two strategies have never been compared head-to-head in an unrestricted predicted hyper-responder population.

STUDY DESIGN, SIZE, DURATION

This study included women with an excessive response to ovarian stimulation (≥18 follicles measuring ≥11 mm) undergoing IVF/ICSI in a GnRH antagonist suppressed cycle between 2014 and 2017. Our primary outcome was clinical pregnancy at 7 weeks after the first embryo transfer. Secondary outcomes included live birth and the development of moderate-to-severe OHSS.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Following GnRH agonist triggering, women were randomized either to cryopreserve all good-quality embryos followed by a frozen embryo transfer in an subsequent artificial cycle or to perform a fresh embryo transfer with intensified luteal phase support (1500 IU hCG on the day of oocyte retrieval, plus oral estradiol 2 mg two times a day, plus 200 mg of micronized vaginal progesterone three times a day).

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 212 patients (106 in each arm) were recruited in the study, with three patients (one in the fresh embryo transfer group and two in the freeze-all group) later withdrawing their consent to participate in the study. One patient in the freeze-all group became pregnant naturally (clinical pregnancy diagnosed 38 days after randomization) prior to the first frozen embryo transfer. The study arms did not vary significantly in terms of the number of oocytes retrieved and embryos produced/transferred. The intention to treat clinical pregnancy and live birth rates (with the latter excluding four cases lost to follow-up: one in the fresh transfer and three in the freeze-all arms, respectively) after the first embryo transfer did not vary significantly among the fresh embryo transfer and freeze-all study arms: 51/105 (48.6%) versus 57/104 (54.8%) and 41/104 (39.4%) versus 42/101 (41.6%), respectively (relative risk for clinical pregnancy 1.13, 95% CI 0.87-1.47; P = 0.41). However, moderate-to-severe OHSS occurred solely in the group that received low-dose hCG (9/105, 8.6%, 95% CI 3.2% to 13.9% vs 0/104, 95% CI 0 to 3.7, P < 0.01).

LIMITATIONS, REASONS FOR CAUTION

The sample size calculation was based on a 19% absolute difference in terms of clinical pregnancy rates, therefore smaller differences, as observed in the trial, cannot be reliably excluded as non-significant.

WIDER IMPLICATIONS OF THE FINDINGS

This study offers the first comparative analysis of two common strategies applied to women performing IVF/ICSI with a high risk to develop OHSS. While pregnancy rates did not vary significantly, a fresh embryo transfer with intensified luteal phase support may still not avoid the risk of moderate-to-severe OHSS and serious consideration should be made before recommending it as a routine first-line treatment. Future trials may allow us to confirm these findings.

STUDY FUNDING/COMPETING INTEREST(S)

The authors have no conflicts of interest to disclose. No external funding was obtained for this study.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier NCT02148393.

TRIAL REGISTRATION DATE

28 May 2014.

DATE OF FIRST PATIENT’S ENROLMENT

30 May 2014.

The use of GnRH-agonist trigger for the final maturation of oocytes in normal and low responders undergoing planned oocyte cryopreservation

STUDY QUESTION

Does GnRH-agonist trigger offer similar maturity rate (MR) in low and normal responders compared to high responders in women undergoing planned oocyte cryopreservation, for whom even a small risk of ovarian hyperstimulation syndrome (OHSS) may not be acceptable?

SUMMARY ANSWER

GnRH-agonist is an appropriate choice for final maturation of oocytes in planned oocyte cryopreservation, regardless of response to stimulation or risk of ovarian hyperstimulation syndrome.

WHAT IS KNOWN ALREADY

Numerous studies have demonstrated the utility of GnRH-agonist trigger for the prevention of ovarian hyperstimulation in high-responder in vitro fertilization cycles. Limited data exist supporting its use in normal or low responders, or in non-infertile women undergoing planned oocyte cryopreservation.

STUDY DESIGN, SIZE, DURATION

Retrospective cohort study of 1189 subjects including all planned oocyte cryopreservation cycles performed at a large, single center, oocyte cryopreservation program from April 2016 to December 2018.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 1680 cycles were included in the study. A total of 57.1% (959/1680) utilized GnRH-agonist for trigger. Demographic and clinical data were collected from the medical record. Maturation rate was calculated for the entire cohort, and by trigger type, using the quotient of Metaphase II (MII) oocytes and retrieved oocytes. A sub-cohort of GnRH-agonist trigger cycles were categorized by peak estradiol (E2) levels and maturation rates compared between groups. Associations were made using Student's t test, ANOVA, Mann-Whitney U and Kruskal-Wallis, where appropriate. A sample size calculation for 90% power with a significance of 5% to detect non-inferiority of <0.05 from a 0.75 maturity rate between subjects with E2 > 3000 pg/mL and E2 < 3000 pg/mL demonstrated the need for at least 116 cycles per group.

MAIN RESULTS AND THE ROLE OF CHANCE

Mean MR was 0.71 ± 0.19 overall, and 0.73 ± 0.18 in the sub-cohort of GnRH-agonist trigger cycles. A total of 611 cycles (63.7%) had peak E2 < 3000, and 331 (34.5%) had E2 > 3000. No significant difference in maturity rate was noted between cycles with E2 levels >3000 pg/mL and <3000 pg/mL (0.72 ± 0.19 vs. 0.74 ± 0.14, P = 0.18), confirming the non-inferiority of maturity rates with GnRH-agonist triggers in cycles with peak E2 < 3000 pg/mL. While lower mean oocytes retrieved and mean MII oocytes were associated with lower peak E2 levels, maturity rate did not significantly differ amongst E2 level groups. Cycles with E2 < 1000 pg/mL had lower MR irrespective of trigger type.

LIMITATIONS, REASONS FOR CAUTION

The retrospective nature cannot entirely exclude selection biases, confounding factors or additional variables that could not be accounted for or were not collected by the electronic medical record. Given the nature of planned oocyte cryopreservation, studies of ongoing pregnancy rates and birth outcomes will naturally be delayed. Lastly, the study population was limited to women undergoing planned oocyte cryopreservation; therefore, the results may not be generalizable to women undergoing in vitro fertilization.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first study specifically comparing the efficacy of GnRH-agonist in patients at lower risk for OHSS to those at high risk, as well the first study evaluating GnRH-agonist's efficacy specifically in planned oocyte cryopreservation cycles.

STUDY FUNDING/COMPETING INTEREST(S)

Study support provided by departmental funds from the Center for Fertility Research and Education-Extend Fertility Medical Practice. BLM discloses personal fees from Ferring Pharmaceuticals and Merck KgAA, unrelated to the submitted work. C.S., M.G., L.R. and J.K. have nothing to disclose.

TRIAL REGISTRATION NUMBER

N/A.

Luteal Support with very Low Daily Dose of Human Chorionic Gonadotropin after Fresh Embryo Transfer as an Alternative to Cycle Segmentation for High Responders Patients Undergoing Gonadotropin-Releasing Hormone Agonist-Triggered IVF

The segmentation of the in vitro fertilization (IVF) cycle, consisting of the freezing of all embryos and the postponement of embryo transfer (ET), has become popular in recent years, with the main purpose of preventing ovarian hyperstimulation syndrome (OHSS) in patients with high response to controlled ovarian stimulation (COS). Indeed cycle segmentation (CS), especially when coupled to a GnRH-agonist trigger, was shown to reduce the incidence of OHSS in high-risk patients. However, CS increases the economic costs and the work amount for IVF laboratories. An alternative strategy is to perform a fresh ET in association with intensive luteal phase pharmacological support, able to overcome the negative effects of the GnRH-agonist trigger on the luteal phase and on endometrial receptivity. In order to compare these two strategies, we performed a retrospective, real-life cohort study including 240 non-polycystic ovarian syndrome (PCO) women with expected high responsiveness to COS (AMH >2.5 ng/mL), who received either fresh ET plus 100 IU daily human chorionic gonadotropin (hCG) as luteal support (FRESH group, n = 133), or cycle segmentation with freezing of all embryos and postponed ET (CS group, n = 107). The primary outcomes were: implantation rate (IR), live birth rate (LBR) after the first ET, and incidence of OHSS. Overall, significantly higher IR and LBR were observed in the CS group than in the FRESH group (42.9% vs. 27.8%, p < 0.05 and 32.7% vs. 19.5%, p < 0.05, respectively); the superiority of CS strategy was particularly evident when 16-19 oocytes were retrieved (LBR 42.2% vs. 9.5%, p = 0.01). Mild OHSS appeared with the same incidence in the two groups, whereas moderate and severe OHSS forms were observed only in the FRESH group (1.5% and 0.8%, respectively). In conclusion, in non-PCO women, high responders submitted to COS with the GnRH-antagonist protocol and GnRH-agonist trigger, CS strategy was associated with higher IR and LBR than the strategy including fresh ET followed by luteal phase support with a low daily hCG dose. CS appears to be advisable, especially when >15 oocytes are retrieved.

Correlation between anti-Mullerian hormone levels and antral follicle counts in polycystic ovary and metabolic syndromes

Anti-Mullerian hormone (AMH) is expressed by the granulosa cells of the pre-antral and small antral follicles in the ovary. AMH serum levels are significantly higher in women with polycystic ovary syndrome (PCOS) due to an increased antral follicle counts (AFC) and a higher production of AMH per antral follicle. This research is a cohort study design with a sample size of 60 female patients with (n = 30) and without PCOS (n = 30) in which the relationship between AMH serum level and other hormonal markers was explored. The following measurements were taken from the patients on the fifth day of the menstrual cycle: AMH, glucose, index of insulin resistance (HOMA/IR), body mass index (BMI), testosterone and cholesterol, lipoproteins, and triglycerides. The study proposes diagnostic criteria for PCOS. A twofold increase in the AMH serum levels was observed in the PCOS group when compared to the control group. The following incremental increases were seen in AMH serum levels: testosterone (18.4%); fasting blood glucose (18%); fasting insulin (83.86%); HOMA/IR (64.23%); mean cholesterol (30%); mean triglycerides (17%); and BMI (26.75%). All differences were considered significant at p ˂ 0.005. The results from the study concluded that monitoring the level of AMH allows for the prediction of ovarian hyperstimulation syndrome (OHSS) during ovulation induction and assisted reproductive technology cycles. Monitoring of anti-Mullerian hormone levels may provide an additional marker for determining treatment strategies when presented with additional risks associated with overweight, hirsutism, type II diabetes, infertility, and cardiovascular disease.

Strangulated internal hernia following severe ovarian hyperstimulation syndrome: a case report

Ovarian hyperstimulation syndrome (OHSS) is a serious complication of ovarian stimulation. Herein, we report a rare case of strangulated internal hernia in a woman with severe OHSS following ovulation induction. A delay in the diagnosis and management of acute abdominal pain can lead to serious problems. The aim of this case report was to highlight the diagnostic difficulties of abdominal pain in women with OHSS, and emphasize the positive effects of imaging and a timely differential diagnosis in clinical practice.

Safety of Ovaleap® (Follitropin Alfa) in Infertile Women Undergoing Superovulation for Assisted Reproductive Technologies: A Multinational Comparative, Prospective Cohort Study

BACKGROUND

Ovaleap^® (follitropin alfa), a recombinant human follicle stimulating hormone, is a biosimilar medicinal product to Gonal-f^® and is used for ovarian stimulation. The main objective of this study was to assess the safety and effectiveness of Ovaleap^® compared to Gonal-f^® in one treatment cycle in routine clinical practice.

METHODS

Safety of Ovaleap^® Follitropin alfa in Infertile women undergoing superovulation for Assisted reproductive technologies (SOFIA) was a prospective cohort study conducted in six European countries. Eligible patients were infertile women undergoing superovulation for assisted reproductive technology, who were administered Ovaleap^® or Gonal-f^® for ovarian stimulation and were naïve to follicle stimulating hormone treatment. The recruitment ratio was 1:1. The primary endpoint was incidence proportion of ovarian hyperstimulation syndrome (OHSS) and the secondary endpoint was OHSS severity (Grades I, II, III). The effect of risk factors or potential confounders on the odds ratio for OHSS incidence as well as treatment effect on OHSS incidence was explored using univariate logistic regression. Pregnancy and live birth rates were also assessed.

RESULTS

A total of 408 women who were administered Ovaleap^® and 409 women who were administered Gonal-f^® were eligible for analysis. The incidence proportion of OHSS was 5.1% (95% CI: 3.4, 7.7) in the Ovaleap^® cohort and 3.2% (95% CI: 1.9, 5.4) in the Gonal-f^® cohort. This difference in OHSS incidence proportion between the two cohorts was not statistically significant neither before (p = 0.159) nor after univariate adjustment for each potential confounder (p > 0.05). The incidence proportion of OHSS severity grades was similar in the two treatment groups (3.4% versus 2.0% for Grade I, 1.2% versus 1.0% for Grade II, and 0.5% versus 0.2% for Grade III, in the Ovaleap^® and Gonal-f^® cohorts, respectively), without a significant statistical difference (p = 0.865, for each grade). Among patients who had embryo transfer, clinical pregnancy rates were 33% and 31% and live birth rates were 27% and 26%, in the two cohorts, respectively.

CONCLUSIONS

Findings from the SOFIA study indicate that the incidence proportions of OHSS and OHSS severity, as well as pregnancy and live birth rates, are similar between Ovaleap^® and Gonal-f^® treatments and corroborate the safety and effectiveness of Ovaleap^® as a biosimilar to Gonal-f^®.

Lipid Metabolic Disorders and Ovarian Hyperstimulation Syndrome: A Retrospective Analysis

Objectives

To evaluate the effect of dyslipidemia on the incidence of moderate and severe Ovarian hyperstimulation syndrome (OHSS) in the duration of assisted reproduction technique (ART).

Methods

The study included 233 moderate and severe OHSS patients who received hospitalization after in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) cycles to avoid severe complications. They were divided into dyslipidemia group and normal lipid metabolism group to evaluate whether dyslipidemia contributes to the development of severe OHSS. Subgroup analysis was set to avoid deviation including the freeze-all group and fresh embryo transfer (ET) group according to whether the eligible women chose fresh embryo transfer immediately after their IVF or ICSI cycles. The main outcome measures included the incidence of moderate OHSS and severe OHSS, total gonadotropin dose, number of oocytes retrieved, age and body mass index (BMI). In the ET groups, the rate of pregnancy is also included for analysis.

Results

In the freeze-all group, lipid metabolism was ultimately identified as the factor affecting the morbidity of severe OHSS and the ones with dyslipidemia were more likely to develop to severe OHSS (P < 0.05), while the incidence of severe OHSS among the ET groups had no statistical significance (P > 0.05).

Conclusion

The findings of this study suggested that dyslipidemia might contribute to the development of OHSS, especially for those patients who chose the cryopreservation of all embryos. It is essential to consider the risk of OHSS in patients with dyslipidemia although they required cryopreservation of all embryos.

Growth differentiation factor 9 inhibits vascular endothelial growth factor expression in human granulosa cells

In aortic endothelial cells, the TGFβ signaling pathway is involved in the regulation of vascular endothelial growth factor (VEGF), which encodes a potent angiogenic factor crucial for the development of ovarian hyperstimulation syndrome. Growth differentiation factor 9 (GDF9) is a member of the TGFβ family and its effect on VEGF expression in human granulosa cells is unknown. In this study, human granulosa cells were collected from patients during the course of oocyte retrieval for in vitro fertilization and were cultured in vitro. After the first 48 h of culture, cells were treated with GDF9 with or without SB431542 (an ALK5 inhibitor) at various doses. The medium was then collected to determine the concentration of VEGF by ELISA. Cellular RNA was collected and extracted for quantification by real-time quantitative fluorescence PCR. Our study showed that GDF9 suppressed VEGF release from human granulosa cells in a dose-dependent manner and also downregulated VEGF mRNA levels in these cells. Furthermore, SB431542 antagonized the suppression of VEGF mRNA by GDF9 and diminished the inhibitory effect of GDF9 on VEGF release by human granulosa cells. Our results indicated that GDF9 can inhibit VEGF expression in human granulosa cells and ALK5 might mediate this process.

Is oocyte maturation rate associated with triptorelin dose used for triggering final oocyte maturation in patients at high risk for severe ovarian hyperstimulation syndrome?

STUDY QUESTION

Are oocyte maturation rates different among 0.1, 0.2 and 0.4 mg triptorelin used for triggering final oocyte maturation in patients at high risk for ovarian hyperstimulation syndrome (OHSS) undergoing ICSI?

SUMMARY ANSWER

A dose of 0.1 mg triptorelin results in similar oocyte maturation rates compared to higher doses of 0.2 and 0.4 mg in patients at high risk for OHSS undergoing ICSI.

WHAT IS KNOWN ALREADY

The GnRH agonist triptorelin is widely used instead of hCG for triggering final oocyte maturation, in order to eliminate the risk of severe OHSS in patients undergoing ovarian stimulation for IVF/ICSI. However, limited data are currently available regarding its optimal dose use for this purpose in patients at high risk for OHSS.

STUDY DESIGN, SIZE, DURATION

A retrospective study was performed between November 2015 and July 2017 in 131 infertile patients at high risk for severe OHSS undergoing ovarian stimulation for ICSI. High risk for severe OHSS was defined as the presence of at least 19 follicles ≥11 mm in diameter on the day of triggering final oocyte maturation.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Ovarian stimulation was performed with recombinant FSH and GnRH antagonists. Patients received 0.1 (n = 42), 0.2 (n = 46) or 0.4 mg (n = 43) triptorelin for triggering final oocyte maturation. Hormonal evaluation of FSH, LH, estradiol (E2) and progesterone (PRG) was carried out on the day of triggering final oocyte maturation, 8 and 36 hours post triggering and 3, 5, 7, and 10 days after triptorelin administration. During this period, all patients were assessed for symptoms and signs indicative of severe OHSS development. Primary outcome measure was oocyte maturation rate, defined as the number of metaphase II (MII) oocytes divided by the number of cumulus-oocyte-complexes retrieved per patient. Results are expressed as median (interquartile range).

MAIN RESULTS AND THE ROLE OF CHANCE

No significant differences in patient baseline characteristics were observed among the 0.1 mg, the 0.2 mg and the 0.4 mg groups. Regarding the primary outcome measure, no differences were observed in oocyte maturation rate among the three groups compared [82.6% (17.8%) versus 83.3% (18.8%) versus 85.1% (17.2%), respectively, P = 0.686].In addition, no significant differences were present among the 0.1 mg, 0.2 mg and 0.4 mg groups, regarding the number of mature (MII) oocytes [21 (13) versus 20 (6) versus 20 (11), respectively; P = 0.582], the number of oocytes retrieved [25.5 (13) versus 24.5 (11) versus 23 (12), respectively; P = 0.452], oocyte retrieval rate [81.0% (17.7%) versus 76.5% (23.5%) versus 75.0% (22.5), respectively; P = 0.088], the number of fertilized (two pronuclei) oocytes [12.5 (9) versus 14.5 (7) versus 14.0 (8), respectively; P = 0.985], fertilization rate [71.7% (22%) versus 77.1% (19.1%) versus 76.6% (23.3%), respectively; P = 0.525] and duration of luteal phase [7 (1) versus 8 (2) versus 7 (1) days, respectively; P = 0.632]. Moreover, no significant differences were present among the three triptorelin groups regarding serum levels of LH, FSH, E2 and PRG at any of the time points assessed following triggering of final oocyte maturation.

LIMITATIONS, REASONS FOR CAUTION

This is a retrospective study, and although there were no differences in the baseline characteristics of the three groups compared, the presence of bias cannot be excluded.

WIDER IMPLICATIONS OF THE FINDINGS

Based on the results of the current study, it appears that triggering final oocyte maturation with a lower (0.1 mg) or a higher dose (0.4 mg) of triptorelin, as compared to the most commonly used dose of 0.2 mg, does not confer any benefit in terms of oocyte maturation rate in patients at high risk for severe OHSS.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was obtained for this study. There are no conflicts of interest.

Should we still perform fresh embryo transfers in ART?

An increasing number of researchers have alluded to the potential benefit of deferring the transfer of embryos produced during assisted reproductive technologies (ARTs) away from ovarian stimulation, using cryopreservation to enable this. The scientific evidence that may justify this recent trend in the use of the so-called 'freeze-all strategy' includes early, mostly small randomised controlled trials that have demonstrated an increase in live birth rates after elective embryo cryopreservation in certain patient populations, as well as evidence from cohort studies and retrospective analyses. What are the risks and benefits of freeze-all strategies in ART, who are the patients in whom it is likely to be advantageous, and does the current evidence allow us to identify situations when deciding that a fresh embryo transfer would be counter-productive? ART professionals are often faced with challenging clinical decisions regarding the best course of treatment for their patient. The purpose of this opinion paper is to provide a clinical guide for whether to perform a fresh embryo transfer or to opt for freezing all embryos in specific situations.

Successful reversal of ovarian hyperstimulation syndrome in a mouse model by rapamycin, an mTOR pathway inhibitor

Ovarian hyperstimulation syndrome (OHSS) is a potentially life-threatening, iatrogenic complication of ovarian stimulation in assisted reproduction technology. This complex syndrome is characterised by enlarged ovaries with multiple corpora luteum, elevated sex steroid hormones in serum and increased capillary permeability. Until now, the pathogenesis of OHSS remains obscure, and no absolute strategy can fully prevent OHSS without any side effect on ovulation and clinical pregnancy. Using cultured human or mouse granulosa cells, our study revealed the time-dependent activation of the mTOR signaling pathway after human chorionic gonadotropin (hCG) treatment. The involvement of the mTOR signaling pathway was also observed in the development of OHSS in a mouse model. Selectively inhibiting mTOR signals by only two injections of rapamycin (2 mg/kg body weight), before or just after hCG treatment, significantly reduced vascular leakage and the severity of OHSS symptoms. Although ovarian angiogenesis was significantly inhibited, rapamycin could not decrease the elevated levels of vascular endothelial growth factor, IL-6 and IL-11 in OHSS ovaries. Further study showed the functional roles of the mTOR signaling pathway in the hyperstimulation-induced ovarian extracellular matrix remodeling as the expression of α2M, a broad proteolytic inhibitor in both ovary and serum, was dramatically decreased after rapamycin treatment. Since a single injection of rapamycin during superovulation had no side effects on ovulation and early embryonic development, we propose rapamycin may be a good candidate to lower and prevent the risk of OHSS in the future.

A decision-making algorithm for performing or cancelling embryo transfer in patients at high risk for ovarian hyperstimulation syndrome after triggering final oocyte maturation with hCG

STUDY QUESTION

Can the grade of ascites, haematocrit (Ht), white blood cell (WBC) count and maximal ovarian diameter (MOD) measured on Day 3 be used to construct a decision-making algorithm for performing or cancelling embryo transfer in patients at high risk for severe ovarian hyperstimulation syndrome (OHSS) after an hCG trigger?

SUMMARY ANSWER

Using cut-offs of ascites grade>2, Ht>39.2%, WBC>12 900/mm³ and MOD>85 mm on Day 3, a decision-making algorithm was constructed that could predict subsequent development of severe OHSS on Day 5 with an AUC of 0.93, a sensitivity of 88.5% and a specificity of 84.2% in high-risk patients triggered with hCG.

WHAT IS KNOWN ALREADY

Despite the increasing popularity of GnRH agonist trigger for final oocyte maturation as a way to prevent OHSS, ≥75% of IVF cycles still involve an hCG trigger. Numerous risk factors and predictive models of OHSS have been proposed, but the measurement of these early predictors is restricted either prior to or during the controlled ovarian stimulation. In high-risk patients triggered with hCG, the identification of luteal-phase predictors assessed post-oocyte retrieval, which reflect the pathophysiological changes leading to severe early OHSS, is currently lacking.

STUDY DESIGN, SIZE, DURATION

A retrospective study of 321 patients at high risk for severe OHSS following hCG triggering of final oocyte maturation. High risk for OHSS was defined as the presence of at least 19 follicles ≥11 mm on the day of triggering of final oocyte maturation.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study includes IVF/ICSI patients at high risk for developing severe OHSS, who administered hCG to trigger final oocyte maturation. Ascites grade, MOD, Ht and WBC were assessed in the luteal phase starting from the day of oocyte retrieval. Outcome measures were the optimal thresholds of ascites grade, MOD, Ht and WBC measured on Day 3 post-oocyte retrieval to predict subsequent severe OHSS development on Day 5. These criteria were used to construct a decision-making algorithm for embryo transfer, based on the estimated probability of severe OHSS development on Day 5.

MAIN RESULTS AND THE ROLE OF CHANCE

The optimal Day 3 cutoffs for severe OHSS prediction on Day 5 were ascites grade>2, Ht>39.2%, WBC>12 900/mm³ and MOD>85 mm. The probability of severe OHSS with no criteria fulfilled on Day 3 is 0% (95% CI: 0–5.5); with one criterion, 0.8% (95% CI: 0.15–4.6); with two criteria, 13.3% (95% CI: 7.4–22.8); with three criteria, 37.2% (95% CI: 24.4–52.1); and with four criteria, 88.9% (95% CI, 67.2–98.1). The predictive model of severe OHSS had an AUC of 0.93 with a sensitivity of 88.5% and a specificity of 84.2%.

LIMITATIONS, REASONS FOR CAUTION

This is a retrospective study, and therefore, it cannot be excluded that non-apparent sources of bias might be present. In addition, we acknowledge the lack of external validation of our model. We have created a web-based calculator (http://ohsspredict.org), for wider access and usage of our tool. By inserting the values of ascites grade, MOD, Ht and WBC of high-risk patients on Day 3 after oocyte retrieval, the clinician instantly receives the predicted probability of severe OHSS development on Day 5.

WIDER IMPLICATIONS OF THE FINDINGS

The present study describes a novel decision-making algorithm for embryo transfer based on ascites, Ht, WBC and MOD measurements on Day 3. The algorithm may be useful for the management of high-risk patients triggered with hCG and for helping the clinician’s decision to proceed with, or to cancel, embryo transfer. It must be emphasized that the availability of the present decision-making algorithm should in no way encourage the use of hCG trigger in patients at high risk for OHSS. In these patients, the recommended approach is the use of GnRH antagonist protocols, GnRH agonist trigger and elective embryo cryopreservation. In addition, in patients triggered with hCG, freezing all embryos and luteal-phase GnRH antagonist administration should be considered for the outpatient management of severe early OHSS and prevention of late OHSS.

STUDY FUNDING/COMPETING INTEREST(S)

NHMRC Early Career Fellowship (GNT1147154) to C.A.V. No conflict of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Gonadotropin-releasing hormone agonist for ovulation trigger - OHSS prevention and use of modified luteal phase support for fresh embryo transfer

The introduction of gonadotrophin-releasing hormone agonist (GnRHa) trigger greatly impacted modern IVF treatment. Patients at low risk of ovarian hyperstimulation syndrome (OHSS) development, undergoing fresh embryo transfer and GnRHa trigger can be offered a virtually OHSS-free treatment with non-inferior reproductive outcomes by using a modified luteal phase support in terms of small boluses of human chorionic gonadotrophin (hCG), daily recombinant luteinizing hormone LH (rLH) or GnRHa. In the OHSS risk patient, GnRHa trigger can safely be performed, followed by a 'freeze-all' policy with a minimal risk of OHSS development and high live birth rates in the subsequent frozen embryo transfer cycle. Importantly, GnRHa trigger opened the 'black box' of the luteal phase, promoting research in the most optimal steroid levels during the luteal phase. GnRHa trigger allows high-dose gonadotropin stimulation to achieve the optimal number of oocytes and embryos needed to ensure the highest chance of live birth. This review thoroughly discusses how the GnRHa trigger concept adds safety and efficacy to modern IVF in terms of OHSS prevention. Furthermore, the optimal luteal phase management after GnRHa trigger in fresh embryo transfer cycles is discussed.

ESHRE guideline: ovarian stimulation for IVF/ICSI†

STUDY QUESTION

What is the recommended management of ovarian stimulation, based on the best available evidence in the literature?

SUMMARY ANSWER

The guideline development group formulated 84 recommendations answering 18 key questions on ovarian stimulation.

WHAT IS KNOWN ALREADY

Ovarian stimulation for IVF/ICSI has been discussed briefly in the National Institute for Health and Care Excellence guideline on fertility problems, and the Royal Australian and New Zealand College of Obstetricians and Gynaecologist has published a statement on ovarian stimulation in assisted reproduction. There are, to our knowledge, no evidence-based guidelines dedicated to the process of ovarian stimulation.

STUDY DESIGN, SIZE, DURATION

The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 8 November 2018 and written in English were included. The critical outcomes for this guideline were efficacy in terms of cumulative live birth rate per started cycle or live birth rate per started cycle, as well as safety in terms of the rate of occurrence of moderate and/or severe ovarian hyperstimulation syndrome (OHSS).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Based on the collected evidence, recommendations were formulated and discussed until consensus was reached within the guideline group. A stakeholder review was organized after finalization of the draft. The final version was approved by the guideline group and the ESHRE Executive Committee.

MAIN RESULTS AND THE ROLE OF CHANCE

The guideline provides 84 recommendations: 7 recommendations on pre-stimulation management, 40 recommendations on LH suppression and gonadotrophin stimulation, 11 recommendations on monitoring during ovarian stimulation, 18 recommendations on triggering of final oocyte maturation and luteal support and 8 recommendations on the prevention of OHSS. These include 61 evidence-based recommendations—of which only 21 were formulated as strong recommendations—and 19 good practice points and 4 research-only recommendations. The guideline includes a strong recommendation for the use of either antral follicle count or anti-Müllerian hormone (instead of other ovarian reserve tests) to predict high and poor response to ovarian stimulation. The guideline also includes a strong recommendation for the use of the GnRH antagonist protocol over the GnRH agonist protocols in the general IVF/ICSI population, based on the comparable efficacy and higher safety. For predicted poor responders, GnRH antagonists and GnRH agonists are equally recommended. With regards to hormone pre-treatment and other adjuvant treatments (metformin, growth hormone (GH), testosterone, dehydroepiandrosterone, aspirin and sildenafil), the guideline group concluded that none are recommended for increasing efficacy or safety.

LIMITATIONS, REASON FOR CAUTION

Several newer interventions are not well studied yet. For most of these interventions, a recommendation against the intervention or a research-only recommendation was formulated based on insufficient evidence. Future studies may require these recommendations to be revised.

WIDER IMPLICATIONS OF THE FINDINGS

The guideline provides clinicians with clear advice on best practice in ovarian stimulation, based on the best evidence available. In addition, a list of research recommendations is provided to promote further studies in ovarian stimulation.

STUDY FUNDING/COMPETING INTEREST(S)

The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payment. F.B. reports research grant from Ferring and consulting fees from Merck, Ferring, Gedeon Richter and speaker’s fees from Merck. N.P. reports research grants from Ferring, MSD, Roche Diagnositics, Theramex and Besins Healthcare; consulting fees from MSD, Ferring and IBSA; and speaker’s fees from Ferring, MSD, Merck Serono, IBSA, Theramex, Besins Healthcare, Gedeon Richter and Roche Diagnostics. A.L.M reports research grants from Ferring, MSD, IBSA, Merck Serono, Gedeon Richter and TEVA and consulting fees from Roche, Beckman-Coulter. G.G. reports consulting fees from MSD, Ferring, Merck Serono, IBSA, Finox, Theramex, Gedeon-Richter, Glycotope, Abbott, Vitrolife, Biosilu, ReprodWissen, Obseva and PregLem and speaker’s fees from MSD, Ferring, Merck Serono, IBSA, Finox, TEVA, Gedeon Richter, Glycotope, Abbott, Vitrolife and Biosilu. E.B. reports research grants from Gedeon Richter; consulting and speaker’s fees from MSD, Ferring, Abbot, Gedeon Richter, Merck Serono, Roche Diagnostics and IBSA; and ownership interest from IVI-RMS Valencia. P.H. reports research grants from Gedeon Richter, Merck, IBSA and Ferring and speaker’s fees from MSD, IBSA, Merck and Gedeon Richter. J.U. reports speaker’s fees from IBSA and Ferring. N.M. reports research grants from MSD, Merck and IBSA; consulting fees from MSD, Merck, IBSA and Ferring and speaker’s fees from MSD, Merck, IBSA, Gedeon Richter and Theramex. M.G. reports speaker’s fees from Merck Serono, Ferring, Gedeon Richter and MSD. S.K.S. reports speaker’s fees from Merck, MSD, Ferring and Pharmasure. E.K. reports speaker’s fees from Merck Serono, Angellini Pharma and MSD. M.K. reports speaker’s fees from Ferring. T.T. reports speaker’s fees from Merck, MSD and MLD. The other authors report no conflicts of interest.

Disclaimer

This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained.

Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type.

ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose. (Full disclaimer available atwww.eshre.eu/guidelines.)

^†ESHRE Pages content is not externally peer reviewed. The manuscript has been approved by the Executive Committee of ESHRE.

Performance of prognostic modelling of high and low ovarian response to ovarian stimulation for IVF

STUDY QUESTION

What is the performance of previously established regression models in predicting low and high ovarian response to 150 μg corifollitropin alfa/GnRH-antagonist ovarian stimulation in an independent dataset?

SUMMARY ANSWER

The outcome of ovarian stimulation with 150 μg corifollitropin alfa in a fixed, multiple dose GnRH-antagonist protocol can be validly predicted using logistic regression models with AMH being of paramount importance.

WHAT IS KNOWN ALREADY

Predictors of ovarian response have been identified in FSH/GnRH agonist protocols as well as ovarian stimulation with corifollitropin alfa/GnRH-antagonist. Multivariable response models have been established already, however, external validation of model performance has so far been lacking.

STUDY DESIGN, SIZE, DURATION

Data from a prospective, multi-centre (n = 5), multi-national, investigator-initiated, observational cohort study were analysed. Infertile women (n = 211), body weight >60 kg, were undergoing ovarian stimulation with 150 μg corifollitropin alfa in a GnRH-antagonist multiple dose protocol for transvaginal oocyte retrieval for IVF. Demographic, sonographic and endocrine parameters were prospectively assessed on cycle Day 2 or 3 of spontaneous menstruation before ovarian stimulation. Main outcomes were low (<6 oocytes) and high (>18 oocytes) ovarian response.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Firstly, previously established prediction models for low ovarian response (LOR) and high ovarian response (HOR) were tested using the original parameters. Secondly, re-estimated parameters generated from the present data were tested on the established models. Thirdly, for the development of new predictive models of both LOR and HOR, several logistic regression models were estimated. Resulting prediction models were compared by means of the area under the receiver operating characteristic curve (AUC) and bias-corrected Akaike's Information Criterion (AICc) to identify the most reasonable model for each scenario.

MAIN RESULTS AND THE ROLE OF CHANCE

The previously established prediction models for low and high response performed remarkably well on this dataset (low response AUC 0.8879 (95% CI: 0.8185-0.9573) and high response AUC 0.8909 (95% CI: 0.8251-0.9568)). A newly developed simplified model for LOR with log-transformed AMH values and only age as another covariate showed an AUC of 0.8920 (95% CI: 0.8237-0.9603) with the lowest AICc of all models compared. For predicting HOR, we suggest a simplified model using AMH, FSH and AFC (AUC of 0.8976, 95% CI: 0.8206-0.9746).

LIMITATIONS, REASONS FOR CAUTION

All analyses were done on data from women with a body weight >60 kg. The newly developed simplified models may suffer from overfitting and need to be tested in further independent data sets.

WIDER IMPLICATIONS OF THE FINDINGS

Patient selection for ovarian stimulation with corifollitropin alfa should utilize established response prediction models. The clinical impact of this needs to be evaluated in future studies.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by university funds. M.O.S., T.L. and I.R.K. have nothing to declare. G.G. has received personal fees and non-financial support from MSD, Ferring, Merck-Serono, Finox, TEVA, IBSA, Glycotope, Abbott, Marckryl Pharma, VitroLife, NMC Healthcare, ReprodWissen, ZIVA and BioSilu.

TRIAL REGISTRATION NUMBER

Not applicable.

Comparison Between PPOS and GnRHa-Long Protocol in Clinical Outcome with the First IVF/ICSI Cycle: A Randomized Clinical Trial

Purpose

To investigate whether progestin-primed ovarian stimulation (PPOS) can be an alternative as gonadotrophin-releasing hormone agonist (GnRHa) long protocol for infertile women with normal ovarian reserve during IVF/ICSI.

Methods

A prospective randomized controlled trial (RCT) including 257 patients was conducted between 1 August 2017 to 1 January 2018. Computerized randomization was performed to assign participants into two treatment groups at a 1:1 ratio: PPOS (130 patients) or GnRHa long protocol (127 patients) followed by their first IVF/ICSI with fresh/frozen embryo transfer. The primary outcome was the number of oocytes retrieved. Patients with normal ovarian reserve undergoing their first IVF/ICSI procedure were included. The embryological and clinical outcomes were measured. Only the first embryo transfer cycle was followed-up.

Results

Basic characteristics such as infertility duration, age, and body mass index (BMI) were comparable in both groups. No significant difference was found in the number (mean ± SD) oocytes retrieved [11.8 ± 6.5 for PPOS vs 11.3 ± 5.6 for GnRHa long protocol] or viable embryos [4.5 ± 3.0 for PPOS vs 4.2 ± 2.9 for GnRHa long protocol] between the groups. No patient from either group experienced a premature LH surge during the whole process of ovarian stimulation. Besides, there was no moderate or severe ovarian hyperstimulation syndrome during the ovarian stimulation in PPOS group while three patients suffered it in the GnRHa long protocol group. There was no significant difference in the clinical pregnancy rate of the first embryos transfer cycle between the two groups.

Conclusion

PPOS in combination with embryo cryopreservation as an ovarian stimulation regimen was as effective as GnRHa long protocol during controlled ovarian stimulation (COH) under different endocrinal mechanisms. It can also achieve comparable embryological and clinical outcomes while reducing the incidence of moderate and severe ovarian hyperstimulation syndrome (OHSS) and HMG dosage. It can be an alternative of the treatments for infertile patients with normal ovarian reserve undergoing IVF as well as traditional protocols.

Trial Registration Number

ChiCTR-INR-17012089.

Trial Registration Date

Chictr.org.cn: 23 July 2017.

Date of First Patient’s Enrollment

1 August 2017.