Luteal phase support for in vitro fertilization/intracytoplasmic sperm injection fresh cycles: a systematic review and network meta-analysis

BACKGROUND

Various luteal phase supports (LPSs) have been proven to increase the pregnancy rate in fresh cycles of in vitro fertilization or intracytoplasmic sperm injection; however, there is still significant debate regarding the optimal use of LPS.

METHODS

A systematic review with the use of a network meta-analysis was performed via electronic searching of Ovid MEDLINE, the Cochrane Library, Embase, Web of Science, ClinicalTrials.gov and Google Scholar (up to January 2021) to compare the effectiveness and safety of various LPSs, as well as to evaluate the effects of different initiations of LPSs on pregnancy outcomes. The primary outcomes included live birth and ongoing pregnancy, with the results presented as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Eighty-nine randomized controlled trials with 29,625 women comparing 14 interventions or placebo/no LPS treatments were included in the meta-analyses. No significant differences were found in terms of the pregnancy outcomes when LPS was started within 48 h after oocyte retrieval versus a delayed initiation between 48 h and 96 h after oocyte retrieval. The addition of gonadotropin-releasing hormone (GnRH) agonists to progesterone vaginal pessaries showed a significant benefit in terms of live birth (OR 1.39, 95% CI 1.08 to 1.78). Only human chorionic gonadotropin (HCG) was found to be more efficacious than the placebo/no LPS treatment in terms of live birth (OR 15.43, 95% CI 2.03 to 117.12, low evidence). Any active LPSs (except for rectal or subcutaneous progesterone) was significantly more efficacious than the placebo/no LPS treatment in terms of ongoing pregnancy, with ORs ranging between 1.77 (95% CI 1.08 to 2.90) for the vaginal progesterone pessary and 2.14 (1.23 to 3.70) for the intramuscular progesterone treatment. Among the comparisons of efficacy and tolerability between the active treatments, the differences were small and very uncertain.

CONCLUSION

Delays in progesterone supplementation until 96 h after oocyte retrieval does not affect pregnancy outcomes. The safety of GnRH agonists during the luteal phase needs to be evaluated in future studies before the applications of these agonists in clinical practice. With comparable efficacy and acceptability, there may be several viable clinical options for LPS.

Supplementation with human menopausal gonadotropin in the gonadotropin-releasing hormone antagonist cycles of women with high AMH: Pregnancy outcomes and serial hormone levels

OBJECTIVE

To evaluate the value of using both HMG and recombinant FSH (r-FSH) in the GnRH antagonist protocol for women with high AMH.

MATERIALS AND METHODS

This retrospective, single-center cohort study was conducted from January 2013 to December 2018. Of 277 GnRH antagonist IVF/ICSI cycles in women with anti-Mullerian hormone (AMH) ≥5 μg/L, 170 cycles receiving the combination of r-FSH and HMG (77 with HMG added at the beginning of the GnRH antagonist cycle and 93 with HMG added after GnRH antagonist administration) and 107 cycles receiving r-FSH alone were analyzed. The dynamic hormone profiles and embryonic and clinical outcomes of the patients were evaluated.

RESULTS

We observed significantly lower serum LH levels in the r-FSH + HMG groups during ovarian stimulation. The serum estradiol and progesterone levels were lower in the r-FSH + HMG groups on the trigger day. Nevertheless, there were no significant differences with respect to the number of oocytes retrieved, maturation, fertilization, blastocyst formation rate or ovarian hyperstimulation syndrome (OHSS). The implantation and live birth rates were increased in the r-FSH + HMG groups compared with the r-FSH alone group, with no statistical significance.

CONCLUSIONS

HMG for LH supplementation in the GnRH antagonist protocol for patients with high AMH is not significantly superior to r-FSH alone in terms of ovarian response and pregnancy outcome. Nevertheless, HMG supplementation might be appropriate for women with an initially inadequate response to r-FSH or intracycle LH deficiency.

Ultrasound guidance versus classical method for intrauterine insemination: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

There is a great controversy regarding the benefits of ultrasound-guided intrauterine insemination (IUI) in improving pregnancy rates. Thus, we aimed to compare ultrasound-guided IUI versus classical IUI regarding the pregnancy rates improvement.

METHODS

A systematic search was done in Cochrane Library, PubMed, ISI web of science, and Scopus during June 2021. We selected randomized clinical trials (RCTs) that compared ultrasound-guided IUI versus classical IUI in different pregnancy outcomes. We extracted the available data from included studies and pooled them in a meta-analysis model using RevMan software. Our primary outcome was clinical pregnancy rate. Our secondary outcomes were miscarriage, live birth rates, and incidence of difficulty reported during the procedure. The overall quality of evidence was assessed through GRADEpro GDT software.

RESULTS

Seven RCTs met our inclusion criteria with a total number of 1338 patients. We found that ultrasound-guided IUI significantly improved the clinical pregnancy rate when compared to the classical group (RR = 1.33, 95% CI [1.05, 1.68], p = 0.02). However, there were no significant differences between both groups in terms of miscarriage and live birth rates. Ultrasound-guided IUI significantly reduced the incidence of difficulty reported during the procedure (RR = 0.42, 95% CI [0.21, 0.84], p = 0.01). The GRADEpro GDT tool showed high quality of evidence for the evaluated outcomes.

CONCLUSIONS

There is evidence of high quality that ultrasound-guided IUI improves the pregnancy rate and reduces the incidence of difficulty reported during the procedure.

Effectiveness and safety of Korean medicine for treating women with unexplained infertility: A multi-center observational study

Background

This study was conducted to demonstrate the effectiveness and safety of herbal medicine and acupuncture treatment in unexplained infertile females.

Methods

One hundred patients were recruited from 3 Korean Medicine hospitals in Korea and they voluntarily signed informed consent agreements. Participants took the Onkyeong-tang (120cc) twice daily between menstrual cycle day (MCD) 3 and 12, and herbal medicine for ovulation and implantation (120cc) twice daily between MCD 13 and 28. They also received acupuncture and moxibustion treatment during 4 menstrual cycles. After the 4 menstrual cycle treatment period, there were 3 menstrual cycle observation periods. The primary outcome is signified by clinical pregnancy rates (CPR) and the secondary outcomes were implantation rates (IR), ongoing pregnancy rates (OPR), and live birth rates.

Results

90 patients completed the study. 13 of the 90 subjects became pregnant. The CPR and IR was 14.44%. 7 of 13 pregnant subjects had continuing pregnancy for over 12 weeks, so that the OPR was 53.85%. The birth rate was 7.78%. All 7 pregnant patients gave birth to their babies and all the babies were live singletons and healthy. There were no serious adverse events.

Conclusions

The findings of this study may provide the possibility of effectiveness and safety of Korea medicine treatment for unexplained infertile women. Further study is required due to lack of control and small sample size in this study.

Development of a suitable manufacturing process for production of a bioactive recombinant equine chorionic gonadotropin (reCG) in CHO-K1 cells

Equine chorionic gonadotropin (eCG) is a heterodimeric glycoprotein hormone produced by pregnant mares that has been used to improve reproductive performance in different domestic species. Several strategies to produce the hormone in a recombinant way have been reported; nevertheless, no approach has been able to produce a recombinant eCG (reCG) with significant in vivo bioactivity or in sufficient quantities for commercial purposes. For this reason, the only current product available on the market consists of partially purified preparations from serum of pregnant mares (PMSG). Herein, we describe a highly efficient process based on third-generation lentiviral vectors as delivery method for the production of reCG in suspension CHO-K1 cells, with productivities above 20 IU 10⁶ cell^-1.d^-1 and 70% purification yields after one purification step. Importantly, reCG demonstrated biological activity in cattle, since around 30 μg of reCG were needed to exert the same biologic effect of 400 IU of PMSG in an ovulation synchronization protocol. The results obtained demonstrate that the developed strategy represents an attractive option for the production of reCG and constitutes an auspicious alternative for the replacement of animals as a source of PMSG.

Comparison of pregnancy outcomes using a time-lapse monitoring system for embryo incubation versus a conventional incubator in in vitro fertilization: An age-stratification analysis

OBJECTIVE

The aim of this study was to compare the pregnancy outcomes of in vitro fertilization with embryo transfer between embryos cultured in a time-lapse monitoring system (TLS) and those cultured in a conventional incubator (CI).

METHODS

The medical records of 250 fertilized embryos from 141 patients undergoing infertility treatment with assisted reproductive technology at a tertiary hospital from June 2018 to May 2020 were reviewed. The study population was divided into TLS and CI groups at a 1 to 1 ratio (125 embryos per group). The primary outcome was the live birth rate.

RESULTS

The TLS group had a significantly higher clinical pregnancy rate (46.4% vs. 27.2%, p=0.002), implantation rate (27.1% vs. 12.0%, p=0.004), and live birth rate (32.0% vs. 18.4%, p=0.013) than the CI group. Furthermore, subgroup analyses of the clinical pregnancy rate and live birth rate in the different age groups favored the TLS group. However, this difference only reached statistical significance in the live birth rate in women aged over 40 years and the clinical pregnancy rate in women aged 35-40 years (p=0.048 and p=0.031, respectively). The miscarriage rate, cleavage rate, and blastocyst rate were comparable.

CONCLUSION

TLS application improved the live birth rate, implantation rate, and clinical pregnancy rate, particularly in the advanced age group in this study, while the other reproductive outcomes were comparable. Large randomized controlled trials are needed to further explore the ramifications of these findings, especially in different age groups.

Non-steroidal anti-inflammatory drugs at embryo transfer on pregnancy rates in cows: A meta-analysis

Non-steroidal anti-inflammatory drugs (NSAIDs) at the time of embryo transfer (ET) are commonly used to improve pregnancy rates in cows. A meta-analysis was conducted on 16 trials from 9 publications involving control (n = 2335) and NSAID-treated (n = 2849) cows. The meta-analysis explained the relative risk (RR) with its 95% confidence interval (CI) for pregnancy per embryo transfer (P/ET) after NSAID treatment under various circumstances. NSAID treatment with was associated on average with a 15% higher P/ET compared to no treatment (RR = 1.15, 95% CI = 1.07 to 1.2). The results also highlight that the use of NSAIDs at the time of ET was particularly effective in cows with difficulty in passing the catheter from the cervix during ET, with 71% more likely P/ET (RR = 1.71, 95% CI = 1.07 to 2.74) with the use of NSAIDs for these cows compared to other cows. The data were too limited to analyse the influence of NSAID molecules (flunixin meglumine [FM] and meloxicam), cyclooxygenase (COX) inhibitor type (non-selective COX inhibitor [both COX-1 and COX-2] and selective COX inhibitor [only COX-2]), embryo processing (embryo production, embryo conservation and embryo quality), stress, synchronization, breed and parity on the relationship between NSAIDs and P/ET.

Multicausal analysis on psychosocial and lifestyle factors among patients undergoing assisted reproductive therapy - with special regard to self-reported and objective measures of pre-treatment habitual physical activity

Background

National, regional and global trends in prevalence of infertility indicate its public health importance, however it effects various life dimensions of individuals and couples as well. Lifestyle habits may counteract with these factors. The aim of the study was the multicausal analysis of psychosocial and lifestyle factors undergoing assisted reproductive therapy (ART) with special regard to pre-treatment habitual physical activity (PA).

Methods

In a cross-sectional, observational cohort study on ART patients (N = 60, age 34.6 ± 5.2 years, BMI 24.2 ± 4.9 kg/m²) with follow up on outcome measures a detailed description was given on PA patterns (ActriGraph GT3X, GPAQ-H) and on general and infertility related distress (BDI-13, FPI).

Results

Respondents reported normal mood state (BDI-13) but moderately high infertility-related distress (FPI) in Social- and very high distress in Sexual Concern. It was revealed that time spent with recreational PA (RPA) could counteract with infertility-related distress (Social Concern R = -0.378, p = 0.013; Relationship Concern R = -0.365, p = 0.019).

In the presence of clinical pregnancy GPAQ-H RPA MET was significantly higher (p = 0.048), in the non-pregnant group cumulative values and work-related PA were higher. Correlations could be found between RPA time and the number of oocytes (R = 0.315, p = 0.045), matured oocytes (R = 0.339, p = 0.030) and embryos (R = 0.294, p = 0.062) by women who reached at least 150 min RPA (GPAQ-H). Multivariate linear regression revealed that the number of oocytes was positively influenced by the GPAQ-H recreation MET (R² = 0.367; F = 10.994, p = 0.004; B = 0.005, p = 0.004, B Constant = 4.604). Regarding the number of embryos (R² = 0.757, F = 17.692, p < 0.001, B Constant = 1.342) positive relationship was found with GPAQ-H RPA MET (B = 0.004, p < 0.001) and negative with BMI (B = -0.167, p = 0.038). It was disclosed (R² = 0.958, F = 408.479, p < 0.001) that higher Very Vigorous Activity (ActiGraph) was accompanied with higher hCG (B = 63.703, p ≤ 0.001). However, time spent with moderate PA (GPAQ-H) (B = 0.002, SE = 0.001, Wald = 3.944, p = 0.047, OR = 1.002) was significantly associated with live births.

Conclusions

Amount of PA alone did not have a positive effect on outcome of ART. Type and intensity seemed to be more significant. Existing differences in response to infertility due to recreational PA suggest the importance of the development of a specific intervention. The robust overestimation of PA in self-reports highlights the need to improve physical literacy of women undergoing ART.

Endometrial preparation for frozen-thawed embryo transfer cycles: a systematic review and network meta-analysis

PURPOSE

To compare the effects of different endometrial preparation protocols for frozen-thawed embryo transfer (FET) cycles and present treatment hierarchy.

METHODS

Systematic review with meta-analysis was performed by electronic searching of MEDLINE, the Cochrane Library, Embase, ClinicalTrials.gov and Google Scholar up to Dec 26, 2020. Randomised controlled trials (RCTs) or observational studies comparing 7 treatment options (natural cycle with or without human chorionic gonadotrophin trigger (mNC or tNC), artificial cycle with or without gonadotropin-releasing hormone agonist suppression (AC+GnRH or AC), aromatase inhibitor, clomiphene citrate, gonadotropin or follicle stimulating hormone) in FET cycles were included. Meta-analyses were performed within random effects models. Primary outcome was live birth presented as odds ratio (OR) with 95% confidence intervals (CIs).

RESULTS

Twenty-six RCTs and 113 cohort studies were included in the meta-analyses. In a network meta-analysis, AC ranked last in effectiveness, with lower live birth rates when compared with other endometrial preparation protocols. In pairwise meta-analyses of observational studies, AC was associated with significant lower live birth rates compared with tNC (OR 0.81, 0.70 to 0.93) and mNC (OR 0.85, 0.77 to 0.93). Women who achieved pregnancy after AC were at an increased risk of pregnancy-induced hypertension (OR 1.82, 1.37 to 2.38), postpartum haemorrhage (OR 2.08, 1.61 to 2.78) and very preterm birth (OR 2.08, 1.45 to 2.94) compared with those after tNC.

CONCLUSION

Natural cycle treatment has a higher chance of live birth and lower risks of PIH, PPH and VPTB than AC for endometrial preparation in women receiving FET cycles.

Optimal Oocyte Number in Controlled Ovarian Stimulation with Gonadotropin-Releasing Hormone Agonist/Antagonist and Day 3 Fresh Embryo Transfer

We aimed to investigate the optimal number of oocytes retrieved in normal responders with the gonadotropin-releasing hormone (GnRH) antagonist (GnRHant) protocol in comparison with the GnRH agonist (GnRHa) long protocol. This retrospective study is based on a single-center cohort including 657 fresh cycles with day 3 embryo transfer using the GnRHa long protocol and the GnRHant flexible protocol at the fertility clinic of a university hospital between 2005 and 2019. The rate ratios (RR) of clinical pregnancy were evaluated using log-binomial regression depending on the categories by the number of retrieved oocytes and pituitary suppression methods. After controlling for age, body mass index, and basal follicle-stimulating hormone, women with 10-11 oocytes retrieved demonstrated a significantly higher chance of clinical pregnancy compared to the reference group (4-5 oocytes) (RR 1.68, 95% CI 1.12-2.53). However, retrieval of more than 11 oocytes did not show a significant difference in pregnancy rates (PR) from the reference group. In women treated with GnRHant, a significantly higher clinical PR was also observed in women with 10-11 oocytes retrieved compared to the reference group (RR 1.90, 95% CI 1.05-3.42). In women treated with GnRHa long protocol, a higher probability of clinical pregnancy was observed (RR 1.30, 95% CI 0.98-1.73) in the group with 8-11 oocytes retrieved and it demonstrated borderline statistical significance (P = 0.07). In summary, the optimal number of oocytes for maximizing the rate of a clinical pregnancy is different according to the method of pituitary suppression. Too many oocytes do not seem to be beneficial for achieving better clinical outcomes.

Timed artificial insemination strategies with or without short-term natural service and pregnancy success in beef heifers

Objective was to compare estrous response, and first service and breeding season pregnancy rates in Angus cross beef heifers that received four progesterone (CIDR, vaginal insert) -based estrous-synchronization treatment regimens for timed artificial insemination (TAI) with or without short-term natural service (NS). Heifers (n = 1744; 4 locations) were assigned a reproductive tract score (RTS: 1 = immature, acyclic to 5 = mature, cyclic), body condition score (BCS: 1 = emaciated to 9 = obese) and temperament score (0 = calm to 1 = excitable). Within location, heifers were assigned to either of four treatment regimens. Heifers in Select-Synch + CIDR (C) + short-term NS (SSC + NS) treatment (n = 438) received 100 μg GnRH im + CIDR on Day -7 and CIDR removal + 25 mg PGF2α (im) + estrus-detection patches in the morning of Day 0 and were subjected to NS (bull to heifer ratio, 1:25) from the morning of Day 2 (48 h from CIDR removal) to evening of Day 8. Heifers in CO-Synch + C (COSC) +TAI + NS treatment (n = 433) received 100 μg GnRH + CIDR on Day -7 and CIDR removal + 25 mg PGF2α im + estrus-detection patches in the morning of Day 0 + 100 μg GnRH im + TAI on Day 2, 60 h from CIDR removal, and were subjected to natural service (bull: heifer, 1:25) from the evening of Day 2 immediately after AI through Day 8. Heifers in COSC + TAI treatment (n = 443) received 100 μg GnRH + CIDR on Day -7 and CIDR removal + 25 mg PGF2α im + estrus-detection patches in the morning of Day 0 + 100 μg GnRH im + TAI on Day 2, 60 h from CIDR removal. Heifers in SSC + split time AI (STAI) treatment (n = 430) received 100 μg GnRH + CIDR on Day -7 and CIDR removal + 25 mg PGF2α im + estrus-detection patches in the morning of Day 0. Heifers determined to be in estrus were inseminated at 64 h after PGF2α (25 mg, im) administration and non-estrous heifers determined to be in estrus 20 h later (at 84 h) were inseminated at that time, whereas remaining non-estrous heifers at 84 h received GnRH (100 μg) and were inseminated concomitantly. In SSC + NS and COSC + TAI + NS treatments, natural service bulls were removed and reintroduced (@ bull: heifer, 1:40) on Day 22 and kept until Day 63. In COSC + TAI and SSC + STAI bulls (bull: heifer, 1:40) were introduced on Day 14 and retained until Day 63. All heifers, irrespective of treatment regimens, were observed for estrus three times a day from Day 2 through Day 8. Pregnancy diagnosis was performed on Day 93, 30 days from end of breeding season. Accounting for temperament (P < 0.0001), BCS (P < 0.0001) and RTS (P < 0.0001), the breeding program influenced the estrous response (P < 0.0001). Heifers in COSC + TAI + NS (86.8%), SSC + STAI (84.9%), and SSC + NS (86.5%) treatments had greater estrous response compared with heifers in COSC + TAI (75.8%) treatment. Accounting for temperament (P < 0.01), BCS (P < 0.05) and RTS (P < 0.01), the treatment regimens influenced first service pregnancy rate (P < 0.05). Heifers in COSC + TAI + NS treatment had greater first service pregnancy rate (60.3%) compared with COSC + TAI (54.2%) (P < 0.05). First service pregnancy rate for heifers in SSC + STAI (59.3%) and SSC + NS (57.3%) treatments did not differ from COSC + TAI + NS and COSC + TAI treatments. Accounting for temperament (P < 0.001), BCS (P < 0.0001) and RTS (P < 0.0001), the treatment regimens influenced breeding season pregnancy rate (P < 0.05). Breeding season pregnancy rate for heifers in COSC + TAI + NS (95.4%) and COSC + STAI (94.5%) treatments were greater than that of heifers in COSC + TAI (90.8%) treatment (P < 0.05), and heifers in SSC + NS (94.1%%) treatment did not differ from heifers in other treatments. In conclusion, progesterone-based CO-Synch timed artificial insemination with short-term natural service treatment regimen resulted in proportionately more pregnancies than without short-term natural service treatment regimen. In addition, 64/84 h split-time AI or natural service following Select-Synch treatment regimen could be implemented as an alternative as these treatment regimens resulted in similar pregnancy rate as progesterone based CO-Synch timed artificial insemination with short-term natural service treatment regimen.

Gastrointestinal nematode control programs in yearling Nellore heifers: Analysis of fecal egg counts, weight gain and reproductive indices

The objective of this study was to evaluate two different gastrointestinal nematode treatment regimens. Fecal egg counts (FECs), proportion of nematode genera, weight gain, body condition score and reproductive indices (estrous cyclicity, conception and pregnancy rates) were evaluated in yearling heifers after imposing two treatment regimens for gastrointestinal nematodes: T1 = 306 calves treated in May and November with 3.5 % doramectin (700 μg/kg) and August (Aug) with saline solution; and T2 = 307 calves treated in May with 3.5 % doramectin (700 μg/kg), in August with 1% moxidectin (200 μg/kg) and in November with 3.5 % doramectin (700 μg/kg). The animals were weighed, and feces were collected for conducting FECs and coproculture. There was imposing of three fixed-time artificial inseminations (TAIs), and estrous cyclic and pregnancy statuses were determined. Cooperia was the most frequent genus detected in both groups. Heifers of the T2, as compared to those in the T1 group, had fewer FECs in November (P ≤  0.05) and greater weight gain and average daily weight gain (P ≤  0.05) from August to November. There tended to be more heifers of the T2 than T1 group estrous cycling (P =  0.07) at the beginning of the breeding season as well as greater pregnancy rates (P =  0.03) and conception rates (P =  0.03) as a result of the second FTAI. The results indicate there is greater reproduction outcomes as a result of strategic control of gastrointestinal nematodes in yearling Nellore heifers using the T1 as compared with T2 treatment regimen.

The association between psychosocial interventions and fertility treatment outcome: A systematic review and meta-analysis

OBJECTIVE

Does psychosocial intervention affect pregnancy outcomes in women and couples undergoing assisted reproductive technology (ART) treatment?.

DESIGN

A systematic review and meta-analysis of Randomized Controlled Trials (RCTs) evaluating the efficacy of psychosocial intervention on pregnancy outcomes in women and couples undergoing ART treatment. The primary outcome was Pregnancy Rates. Secondary outcomes were Live Birth Rate (LBR) and Abortion Rate (AR).

MATERIALS AND METHODS

Databases searched were Pubmed, PsycINFO, Embase, CINAHL and The Cochrane Library. 1439 records were screened, 15 were eligible and included in the meta-analyses (N = 2434). Data was extracted using the Covidence software. Effect sizes were reported as relative risks with 95% confidence-intervals and p-values.

RESULTS

A positive association was found between psychosocial intervention and pregnancy rates (RR = 1.12 CI=(1.01;1.24), p = 0.033). Long-duration interventions and mind-body intervention types were found to be associated with increased pregnancy rates (RR 1.21, CI= (1.04;1.43), p = 0.017) and (RR = 1.25, CI= (1.00;1.55), p = 0.046) respectively. Q and I²tests suggested no to low heterogeneity. Funnel plots, Trim and Fill analyses and Fail-safe numbers were applied to adjust for possible publication bias.

CONCLUSIONS

Our findings suggest a positive association between psychosocial interventions, particularly long-duration interventions, and pregnancy rate in infertile women and couples in ART treatment. The findings are in line with findings from other reviews and meta-analyses exploring the same topic. More good quality RCTs need to be performed to increase the quality of guidance for infertile women and couples. The effect of psychosocial interventions on LBR and AR remain to be examined.

Semen parameters on the intracytoplasmic sperm injection day: Predictive values and cutoff thresholds of success

OBJECTIVE

This study was conducted to investigate the relationship of semen parameters in samples used for intracytoplasmic sperm injection (ICSI) with fertilization and pregnancy rates in infertile couples.

METHODS

In this prospective study of Infertile couples with male factor infertility that had undergone ICSI, fractions of the same semen samples obtained for microinjection (to ensure the best predictability) were evaluated to determine the semen parameters and sperm DNA fragmentation index (DFI) on the day of oocyte recovery.

RESULTS

In total, 120 couples completed the study and were subdivided into fertilized (n=87) and non-fertilized couples (n=33). The fertilized couples were further classified into pregnant (n=48) and non-pregnant (n=39) couples. Compared to non-fertilized and non-pregnant couples, fertilized and pregnant couples showed statistically significantly higher sperm viability and percentage of normal sperm morphology, as well as significantly lower sperm DFI values. A receiver operating characteristic curve analysis of data from the 120 ICSI cycles showed that sperm viability, normal sperm morphology percentages, and sperm DFI were significant prognostic indicators of fertilization at cutoff values of 40%, 7%, and 46%, respectively. A sperm DFI of 46% showed sensitivity and specificity of 95% and 90%, respectively, for predicting fertilization, and no clinical pregnancies occurred in couples with a sperm DFI above 46%.

CONCLUSION

Semen parameters from the ICSI day sample, especially sperm viability, normal morphology, and DFI, had an impact on fertilization and pregnancy outcomes in ICSI cycles.

Efficacy of growth hormone supplementation with ultrashort GnRH antagonist in IVF/ICSI for poor responders; randomized controlled trial

OBJECTIVES

To compare the ICSI-ET outcomes in poor responders who underwent ovarian stimulation by the ultrashort GnRH antagonist protocol with or without adjuvant GH injection.

MATERIAL AND METHODS

This randomized controlled study was conducted at Al-Azhar University from December-2018 to June-2019 upon 156 participants. All patients received the same preparations. After randomization, in the study group, women have received GH 4 IU/day subcutaneous injection from the second day of the cycle stopped one day before ovum pickup. While in the control group, women have received subcutaneous saline in the same dosing as in the study group. After intervention, all procedures were the same in both groups. The main outcome measure was the clinical pregnancy rate. Statistical analysis was based on the intention-to-treat population.

RESULTS

Both groups were comparable with regard their baseline characteristics (p-values > 0.05). Ovulation characteristics were comparable (p-values > 0.05). The level of E2 is significantly (p-value = 0.003) higher in the GH group. The oocyte retrieved number was significantly (p-value < 0.001) higher in the GH group 4.94 ± 1.77 than in the control group 3.74 ± 1.82. The mean number of MII oocytes was significantly (p-value < 0.001) higher in the GH group 3.3 ± 1.36 than in the control group 2.29 ± 1.24. Fertilization characteristics, implantation rate, pregnancy rate were comparable (p-values > 0.05).

CONCLUSION

Despite the fact that this study showed no significant increase in the clinical and chemical pregnancy rates by the addition of GH to the ultrashort antagonist protocol in poor responders, the number of retrieved oocytes was significantly higher in the GH group.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03759301.

Ultrasound guidance versus the classical method for intrauterine insemination in oral medication-stimulated cycles: A randomized, single-blind, controlled trial

OBJECTIVE

This study was conducted to compare the pregnancy rates of ultrasound-guided intrauterine insemination (UG-IUI) and classical intrauterine insemination (C-IUI) cycles.

STUDY DESIGN

A total of 320 infertile women were enrolled and randomized into an UG-IUI group, and a C-IUI group. All participants received an oral medication for ovarian stimulation. With both groups, the IUIs were scheduled and performed by doctors in their residency and fellowship training, under supervision. The duration and difficulty of the procedures were assessed. A pregnancy test was offered 3 weeks later if the participants did not have menstruation.

RESULTS

The demographic and other baseline characteristics of the groups (baseline hormone levels, cervical length, uterine position, endometrial thickness, and expertise of the providers) were comparable. The pregnancy rates were similar, with 6.9 % and 6.3 % for the UG-IUI and C-IUI groups, respectively. In the UG-IUI group, the pregnancy rate of the multigravida women was three times higher than that of the nulligravida women (15.4 % vs. 5.0 %; p = 0.13). Although the duration of the procedure was shorter for the UG-IUI group (p < 0.05), the level of difficulty was similar for the two groups.

CONCLUSIONS

For oral-medication stimulated cycles, UG-IUI did not increase the pregnancy rate more than with C-IUI. However, the pregnancy rate tended to increase with UG-IUI for multigravida women.

Fertility in patients with untreated rectosigmoid endometriosis

RESEARCH QUESTION

Several studies have investigated reproductive outcomes following surgical treatment of colorectal endometriosis, mainly segmental colorectal resection. This study examines pregnancy and live birth rates of women with rectosigmoid endometriosis not treated by surgery.

DESIGN

A retrospective analysis of data collected between May 2009 and January 2020 related to 215 women affected by rectosigmoid endometriosis wishing to conceive. Patients had a diagnosis of rectosigmoid endometriosis by transvaginal ultrasonography and magnetic resonance imaging enema. Patients with estimated bowel stenosis >70% at computed tomographic colonography and/or subocclusive/occlusive symptoms were excluded.

RESULTS

During the median length of follow-up of 31 months (range 13-63 months), the total pregnancy and live birth rates of the study population were 47.9% and 45.1%, respectively. Sixty-two women had a live birth after natural conception (28.8%; 95% confidence interval [CI] 22.8-35.6%) with a median time required to conceive of 10 months (range 2-34 months). Eighty-three women underwent infertility treatments (38.6%, 95% CI 32.1-45.5%); among these, 68 patients underwent IVF either directly (n = 51) or after intrauterine insemination (IUI) failure (n = 17). Time to conception was significantly higher in women having conceived by IVF than in those having conceived naturally (P < 0.001) or by IUI (P = 0.006). In patients undergoing IVF cycles, a worsening of some pain and intestinal symptoms was observed.

CONCLUSIONS

At median follow-up of 31 months, women with rectosigmoid endometriosis have a 48% pregnancy rate. However, these patients must be referred to centres specialized in managing endometriosis to properly assess symptoms and degree of bowel stenosis.

Modified endometriosis fertility index is more accurate to predict the non-ART pregnancy rate following surgery: a cohort of Chinese women

OBJECTIVE

To examine whether a modified endometriosis fertility index (EFI) can better predict the rate of pregnancy without assisted reproductive technologies (ART) after laparoscopic surgery in infertile Chinese women with endometriosis.

METHODS

564 infertile women undergoing laparoscopy for endometriosis were retrospectively collected from January 2014 to December 2018. 472 patients were used to modify the EFI based on new, optimal cutoffs for its predictor variables. The predictive accuracy of the modified EFI was examined in the other 92 patients.

RESULTS

Among the patients for the EFI modification, the multivariable Cox regression results showed that historical factors made more contribution in predicting non-ART pregnancy rate than surgical factors both in modified EFI (C-index: historical factors 0.617 vs surgical factors 0.558) and original EFI (C-index: historical factors 0.600 vs surgical factors 0.549). No significant relationship between the prior pregnancy and post-operative non-ART pregnancy rates was detected by both modified EFI and original EFI (p = 0.530 and 0.802, respectively). To assess the predictive effect of modified EFI, the two versions of modified EFI not only had higher predictive accuracy (C-index: 0.627 and 0.632) for non-ART pregnancy rates than that of the original EFI (C-index: 0.602) in the patients undergoing surgery during 2014-2017, but also higher than that of the original EFI (C-index: 0.638 and 0.612 vs 0.560) in the externally validated population in 2018.

CONCLUSIONS

A modified EFI based on population-specific optimal cutoffs and weights might be more suitable for estimating the rate of non-ART pregnancy after laparoscopic surgery in infertile women with endometriosis.

Pregnancy rates and perinatal outcomes in women with systemic lupus erythematosus: data from the Korean national health claims database

INTRODUCTION/OBJECTIVES

The pregnancy rate in systemic lupus erythematosus (SLE) is not fully understood and comparisons of adverse pregnancy outcomes (APOs) with SLE versus the general population are limited. This study aimed to estimate the pregnancy rate and APOs in Korean SLE compared to those without SLE.

METHOD

Pregnant women were identified using the ICD-10 codes for delivery and abortion in the Korean national health claims database (2013-2015). APOs were classified as fetal loss, intrauterine growth retardation (IUGR), pre-eclampsia/eclampsia, and gestational diabetes. Annual incidence rates (IRs) of pregnancy and APOs were calculated in women with SLE and the general population without SLE and the two groups were compared using age-adjusted incidence rate ratios (IRRs). Age-stratified IRRs were further analyzed.

RESULTS

The annual IRs of pregnancy in SLE were 29.54-30.70 per 1000 persons. The IRRs were lower in women with SLE than in the general population: 0.68 (0.61-0.76), 0.66 (0.60-0.74), and 0.74 (0.66-0.82) in each respective year. The IRRs of fetal loss, IUGR, and pre-eclampsia/eclampsia were 1.30 (1.14-1.49), 4.65 (3.55-6.09), and 3.43 (2.70-4.36), respectively. However, the IRR of gestational diabetes in SLE did not significantly differ from that of women without SLE. Among the APOs, fetal loss, IUGR, and pre-eclampsia/eclampsia showed decreasing tendencies as age increased.

CONCLUSIONS

Pregnancy rates in SLE were approximately 30% lower than those in the general population. Except for gestational diabetes, fetal loss, IUGR, and pre-eclampsia/eclampsia were higher in SLE and showed a decreasing tendency with age. Key Points • This population-based cohort study showed that pregnancy rates in SLE were approximately 30% lower than those in the general population. • SLE had a 1.3-fold higher rate of fetal loss, more than 4-fold higher IUGR rate, and more than 3-fold pre-eclampsia or eclampsia rate compared with the general population. • Adverse pregnancy outcomes in SLE showed a decreasing tendency with age.

Monitoring estrous activity in pasture-based dairy cows

Correctly identifying cows in estrus and inseminating them at the optimal time are critical components of reproductive management. Technologies for detecting cows in estrus have developed from tail paint in the 1970's to automated activity monitors and mount detectors in recent decades. The objectives of this study were to identify animal characteristics associated with estrous behaviour, measured using a mount detector (FlashMate; Farmshed Labs) and an accelerometer-based activity monitor (Moomonitor, Dairymaster), to examine the relationship between estrous behaviour measured by both devices, and to examine the characteristics associated with pregnancy per AI. Four hundred and sixty eight lactating dairy cows managed on three research farms were enrolled and data were available from 465 cows and 369 cows with Moomonitor and FlashMate data, respectively. Of 234 cows that provided both Moomonitor and FlashMate data, the mean (±SEM) onset of device activation occurred 1.1 (±0.4) h earlier with the Moomonitor compared with the FlashMate. The mean (±SD) duration of Moomonitor activity and FlashMate activity was 17.2 ± 6.1 h and 8.7 ± 5.8 h, respectively. The duration of Moomonitor activity and FlashMate activity was negatively associated with total milk yield during the first five weeks of lactation. The duration of FlashMate activity, but not the duration of Moomonitor activity was positively associated with days in milk. Pregnancy per AI was positively associated with BCS, days in milk, the duration of FlashMate activity and the interval from the onset of Moomonitor and FlashMate activity to AI. Inseminating cows ≤2 h after FlashMate activation or ≤4 h after Moomonitor activation was associated with reduced odds of pregnancy compared with later timing of AI. Overall, 55% of cows received mounts for ≤8 h, highlighting the need for ≥3 periods of estrous observation daily or the use of estrous detection aids that continuously monitor cows. Finally, the study reiterated the importance of maximising body condition score and days in milk at breeding to increase behavioural expression of estrus and pregnancy per AI.

The benefits of varicocele repair for achieving pregnancy in male infertility: A systematic review and meta-analysis

Introduction

Varicocele is one of the most common treatable causes of male infertility. However, the decision to perform varicocelectomy before starting a fertility program remains controversial. This study aimed to thoroughly review and analyze the benefit of varicocele repair and its impact on the success rate of a fertility program.

Materials and methods

A systematic literature search was performed using MEDLINE, Cochrane Library, and Wiley Library. The primary outcome was the pregnancy rate, and the secondary outcomes were live birth rate and surgical sperm retrieval success rate. Outcomes were compared between men who underwent treatment for a varicocele and those that did not. The pooled analysis data are presented as odds ratios with 95% confidence intervals.

Results

A total of 31 articles were included in the meta-analysis. The pregnancy rate was significantly higher in the treated group (odds ratio = 1.82; 95% confidence interval: 1.37-2.41; P < 0.0001) along with the live birth rate (odds ratio = 2.80; 95% confidence interval: 1.67-4.72; P = 0.0001). The further subgroup analysis revealed a higher pregnancy rate in treated men with azoospermia, subnormal semen parameters, and normozoospermia (P = 0.04, P = 0.0005, and P = 0.002, respectively), while the live birth rate was only significantly higher in the treated men with subnormal semen parameters and normozoospermia (P = 0.001 and P < 0.0001). Treated varicocele also led to a higher sperm retrieval rate in azoospermic patients (odds ratio = 1.69; 95% confidence interval: 1.16-2.45; P = 0.006).

Conclusions

Varicocele repair increased the pregnancy and live birth rates regardless the semen analysis result, along with the sperm retrieval success rate in azoospermic men. Thus, varicocele repair may be beneficial prior to joining a fertility program.

The impact of a poor quality embryo on the implantation chance of a good quality one when transferred together: A study on double blastocyst transfers

OBJECTIVE

Embryo quality assessment with morphological evaluation remains the first-line method of assessment to select the best embryo for transfer. We aimed to determine if an effect of poor quality embryos on good quality ones exists, whether by a paracrine effect or an adverse endometrial influence, when they are transferred together.

MATERIALS AND METHODS

We included 412 couples, who underwent intracytoplasmic sperm injection (ICSI) cycles in a tertiary IVF center. Single embryo transfer with a good quality embryo and double embryo transfers with a good + poor quality embryo were evaluated. Overall pregnancy (PR) and live birth rates (LBR) were our main outcome measures.

RESULTS

When PR and LBR are compared, there was no statistical significance between single embryo transfer (SET) and double embryo transfer (DET) groups (51.7 % vs 53.7 %, p = 0.620 and 47 % vs 43.1 %, p = 0.117). When the PR and LBRs were compared between SET from poor cohort and DET group, the outcomes were better in DET group (22.1 % vs 53.7 %, p < 0.001 and 22.1 % vs 43.1 %, p < 0.001). The PR and LBRs of SET from good cohort were significantly better than those of DET (64.4 % vs 53.7 %, p < 0.001 and 57.7 % vs 43.1, p < 0.001). When the PR and LBRs of SET from good cohort and SET from poor cohort were compared, better results were obtained in SET from good cohort.

CONCLUSION

The addition of poor quality embryo even is of benefit to the LBR, in the setting of when there is only one good quality blastocyst available for the transfer.

Comparable Outcomes Using Oral Dydrogesterone Vs. Micronized Vaginal Progesterone in Frozen Embryo Transfer: a Retrospective Cohort Study

This retrospective study was conducted to determine whether using oral dydrogesterone (DYD) instead of micronized vaginal progesterone (MVP) in frozen embryo transfer (FET) cycles affects pregnancy outcomes. Women undergoing autologous FET in an academic fertility center were evaluated. Uses of 10 mg TID oral DYD or MVP for patients treated in FET cycles (artificial and ovulatory cycle, separately) were compared. The main outcome measure was live birth rates in each group. The study analyzed 599 cycles that occurred from January 2018 through December 2019. Chemical and clinical pregnancy rates were comparable between DYD vs. MVP groups (41.6% vs. 38.1%; P = 0.44 and 36.7% vs. 31.4%; P = 0.18, respectively). The ongoing pregnancy and delivery rates (29% vs. 22%, P = 0.06), as well as abortion rate (12.3% vs. 15.8%, P = 0.2), were comparable between the two groups. In a case-control sub-analysis of artificial FET cycles, we found comparable results between the two modes of luteal support. Similarly, results were comparable in ovulatory cycles using these medications for luteal support. Chemical and clinical pregnancy rates were comparable with DYD vs. MVP, in artificial FET (33.7% vs. 34.8%; P = 0.89 and 27.7% vs. 27.5%; P = 1), and in ovulatory FET (46.5% vs. 43.9%; P = 0.71 and 42.3% vs. 38.2%; P = 0.53), respectively. Our results indicate that in FET, pregnancy outcomes with oral DYD were not inferior to those with MVP.

An agent-based simulation model to compare different reproductive strategies in cow-calf operations: Technical performance

The objective of this study was to create a stochastic, agent-based simulation model of a synthetic population of beef cattle, and then use it to compare the technical performance of different reproductive strategies. The model was parameterized using data from a real beef cattle herd and from the peer-reviewed scientific literature to represent a Nelore cattle herd in the state of São Paulo, Brazil. Ten scenarios were evaluated: natural mating (NM) only (ONM); one timed artificial insemination (TAI) plus NM (1TAI + NM); two TAI plus NM, with 24, 32, and 40 days between inseminations (2TAI/24 + NM, 2TAI/32 + NM, and 2TAI/40 + NM, respectively); three TAI without NM, with 24, 32, and 40 days between TAI (3TAI/24, 3TAI/32, and 3TAI/40, respectively); and three TAI plus NM, with 24 and 32 days (3TAI/24 + NM and 3TAI/32 + NM, respectively). NM began 10 days after the last TAI and was performed until the end of the breeding season. The size of the female herd was set to contain up to 400 individuals. The bull population was established at 0, 7, or 15 bulls depending on the used scenario. Simulation was performed for 5000 days. The outcomes for each scenario are means ± S.E. assessed on 32 farms at 1-day time intervals and on an animal-by-animal basis after steady state was reached (1825 days). The 3TAI/24 + NM scenario resulted in a greater number of births (279.85 ± 0.47 births), while the ONM scenario had the least value (202.38 ± 0.43 births). The heaviest males and females at weaning belonged to 3TAI/24, with 190.85 ± 0.17 kg for males and 173.89 ± 0.13 kg for females. The ONM scenario had the lightest males (166.84 ± 0.18 kg) and females (151.75 ± 0.16 kg). The greatest and least total pregnancy rates were found in 3TAI/24 + NM (0.91 ± 0.00) and ONM (0.62 ± 0.00), respectively. The ONM scenario required 52.5 days more than scenarios that included TAI to reach 50% of pregnancy. The greatest ages at culling for cows was 3TAI/24 + NM (3658.88 ± 10.41 days). In contrast, the lowest age at culling was found in ONM (2823.93 ± 8.28 days). We concluded that the proposed model represents the main interactions of a real beef cattle herd. It has all the advantages of a physical experiment, but does not require incurring significant expenses nor altering the real system. This study offers evidence that the scenarios that present the best technical performance are those that used TAI with a 24-day interval between inseminations.

The effect of altering the timing of GnRH administration and artificial insemination in a modified 5-d CO-Synch protocol using sex-sorted semen in dairy heifers

The objective was to optimize fertility in a modified 5-d CO-Synch protocol by altering the timing of GnRH administration and AI. Holstein heifers (14-16 mo) received a controlled internal drug releasing device (CIDR) on d 0 and on d 5, CIDR were removed, prostaglandin F2α was administered and estrus detection patches were applied. Estrus was detected at 36, 48, 56 and 72 h after CIDR removal. In Experiment 1, control heifers (n = 195) received GnRH concurrent with timed-AI (TAI) 72 h after CIDR removal, regardless of expression of estrus. Treatment heifers expressing estrus at 36 or 48 h were AI at 56 h (n = 101) and the remaining heifers were randomly assigned to one of two groups: GnRH administration at 56 h and TAI at 72 h (GnRH56, n = 147) or GnRH administered concurrently with TAI at 72 h (GnRH72, n = 148). In Experiment 2, heifers expressing estrus at 36 or 48 h following CIDR removal were AI at 56 h (n = 118) and the remaining heifers were either TAI at 72 h (TAI72, n = 102) or 80 h (TAI80, n = 102), with only heifers not displaying estrus by TAI given GnRH concurrent with AI. All heifers were inseminated with sex-sorted semen and pregnancy diagnosis was performed at 28 d following TAI. In Experiment 1, estrus rate (P = 0.81) and pregnancy per AI (P/AI; P = 0.34) did not differ among control, GnRH56 and GnRH72 groups, so GnRH56 and GnRH72 groups were combined into one split-TAI (STAI) group. The P/AI was greater in heifers displaying estrus by 48 h compared to those not displaying estrus and receiving GnRH in both groups (69.5 vs. 31.3%; P < 0.01) and there was a tendency for P/AI to increase in STAI heifers displaying estrus compared to control heifers displaying estrus (73.3 vs. 62.1%; P = 0.10). In Experiment 2, the estrus rate was increased in TAI80 compared to TAI72 heifers (81.4 vs. 62.7%, P < 0.01); however, there was no difference in P/AI (P = 0.74). Heifers displaying estrus in the TAI72 group had a greater P/AI than heifers not displaying estrus in either group (P < 0.01) and tended to have a greater P/AI than heifers in estrus in the TAI80 group (87.5 vs. 69.9%, P = 0.07). Across both experiments, P/AI was increased in heifers that displayed estrus before AI compared with heifers that did not and performing a STAI tended to increase P/AI in heifers that displayed estrus before AI. Other attempts made to optimize P/AI in the modified 5-d CO-Synch protocol by altering the timing of GnRH administration and/or AI were unsuccessful.