Prevention and treatment of moderate and severe ovarian hyperstimulation syndrome: a guideline

GnRH ability to release FSH and LH in women with functional hypothalamic amenorrhea: a retrospective cohort study about women with and without polycystic ovarian morphology

Nearly 50% of women with functional hypothalamic amenorrhea (FHA) reveal polycystic ovarian morphology (PCOM), a known risk factor for ovarian hyperstimulation syndrome. However, gonadotropin releasing hormone-agonist (GnRH-a) triggers are not recommended in FHA, since an inadequate endogenous surge in luteinizing hormone (LH) is expected. We aimed to challenge this concept and evaluated LH levels after GnRH stimulation in FHA-women with and without PCOM. In a retrospective cohort study, 82 women with FHA, who underwent a GnRH stimulation test, were included. Thirty-five women revealed PCOM (42.7%). Twenty minutes after GnRH stimulation, there was an increase of serum LH levels in FHA-PCOM (median basal: 2.7 mIU/mL, IQR 1.1-4.6 versus median stimulated: 13.5 mIU/mL, IQR 7.8-21.6, p < 0.001) and in FHA-nonPCOM patients (median basal: 2.5 mIU/mL, IQR 0.5-3.9 versus median stimulated: 5.7 mIU/mL, IQR 2.4-13.9, p < 0.001). Overall, positive correlations (p < 0.001) were found between basal and stimulated LH levels. In FHA-PCOM patients, 42.9% of patients revealed stimulated LH levels >15 mIU/mL, while this was the case in 19.1% of FHA-nonPCOM patients (p = 0.034). In women with FHA-PCOM, ovulation induction with a GnRH-a trigger might be feasible. Future research should focus on the prediction of an adequate response to GnRH triggers in the IVF setting.

Less is more: assessing trigger types in planned oocyte cryopreservation cycles

PURPOSE

To compare oocyte yield and maturation with dual vs. agonist-only trigger for individuals with unknown fertility undergoing planned oocyte cryopreservation.

METHODS

Retrospective cohort study of 1002 planned oocyte cryopreservation cycles among 864 patients from January 2010 to March 2023 who received gonadotropin-releasing hormone agonist-only (GnRHa-only) trigger vs. "dual trigger" or GnRH-a with human chorionic gonadotropin (HCG) 1500-10,000 IU. The main outcomes were total number of oocytes retrieved, mature oocytes, and maturity rate.

RESULTS

After adjusting for age, anti-Müllerian hormone, body mass index, antral follicle count, and max gonadotropin dose, all dual trigger groups had significantly lower oocytes retrieved compared with the GnRHa-only trigger (p-values < 0.02). Additionally, the maturation rate was 10% lower in dual trigger with HCG 10,000 IU compared to GnRH agonist-only trigger (rate ratio = 0.9, p = 0.003). Dual triggers with lower doses of HCG (1500 and 5000 IU) had higher amounts of oocytes retrieved than dual trigger with HCG 10,000 IU, but there was no difference in maturity rate within dual triggers.

CONCLUSION

In a cohort undergoing planned oocyte cryopreservation, the GnRHa-only trigger had higher oocyte yield compared to dual triggers after adjusting for age, anti-Müllerian hormone, body mass index, antral follicle count, and gonadotropin dosing. GnRHa-only triggers have a higher maturity rate than a dual trigger with high HCG. A prospective study is needed to evaluate this further to remove treatment assignment bias.

Visualization analysis of ovarian hyperstimulation syndrome based on bibliometrics

OBJECTIVES

This study offers valuable insights into the research hotspots and trends related to ovarian hyperstimulation syndrome (OHSS). By systematically analyzing articles published on the subject up to July 15, 2024, it provides significant perspectives for future research endeavors.

METHODS

A literature search was executed utilizing the Web of Science core database to retrieve relevant records, with case reports subsequently reassigned to a separate file. During the analysis phase, countries, institutions, authors, journals, references, and keywords underwent thorough examination using tools such as VOSviewer v1.6.10, CiteSpace, R package, and Microsoft Excel 2021.

RESULTS

From the inception of the database to July 15, 2024, a total of 1125 articles were retrieved, including 255 case reports, with a citation count of 23,768. The top 5 countries with the highest article counts were China, the USA, Ireland, the United Kingdom, and Spain. In terms of institutions, Tel Aviv University, Zhengzhou University, Aristotle University of Thessaloniki, Cairo University, and Free University of Brussels were the leading contributors, with Tel Aviv University having the highest number of published articles. Keywords were systematically classified into 4 clusters within the coverage keyword network: diagnosis and clinical manifestations; risk factors and pathogenesis; prevention and treatment; and prognosis and complications. The case reports primarily focused on patients with clinical manifestations of pleural and abdominal fluid accumulation, venous thrombosis, and, in some cases, fatal outcomes.

CONCLUSION

The present study conducts a bibliometric analysis of OHSS case reports to understand its prevalence and trends. The study highlights the shift towards advanced assisted reproduction technologies and prophylactic medication as research hotspots, offering valuable guidance for future OHSS research.

Recurrent spontaneous ovarian hyperstimulation in a young nonpregnant Chinese woman with Rathke cleft cyst and a KISS1R variant: A rare case report and literature review

Unexplained spontaneous ovarian hyperstimulation syndrome (sOHSS) in a nonpregnant young woman is rare, with fewer than five cases documented in the literature. Although four distinct causative types of sOHSS have been identified, some cases remain beyond the scope of our current understanding. A young Chinese woman with sOHSS presented on multiple occasions with sOHSS between the ages of 18.6 and 20.6 years, with acute abdominal discomfort, ascites, hemoconcentration, and pronounced ovarian enlargement coinciding with minor ovulatory anomalies. During the most recent episode, concern regarding a malignant ovarian neoplasm led to emergent unilateral salpingo-oophorectomy. Remarkably, her menstrual cycle normalized after surgery, with no subsequent recurrence of sOHSS. Subsequent diagnostic evaluations identified a Rathke cleft cyst (RCC) in the pituitary gland and a heterozygous mutation in the KISS1R gene. Neither of these findings corresponded with any of the four informally recognized causes of sOHSS, suggesting a hitherto unrecognized pathology. RCCs may cause OHSS by disrupting the endocrine system, while interactions between the kisspeptin system and estradiol may reach a critical threshold, culminating in sOHSS. This case provides important insights into sOHSS and will hopefully spearhead further research into pituitary anomalies and the intricacies of the kisspeptin system. Clinicians are urged to maintain a high level of vigilance for similar presentations and ensure timely and tailored therapeutic interventions.

Spontaneous Ovarian Hyperstimulation Syndrome in Natural Conception: A Case Report

Ovarian hyperstimulation syndrome (OHSS) is a serious condition usually associated with assisted reproductive technologies, but spontaneous OHSS occurring in natural pregnancies is a rare and often overlooked entity. We report the case of a 28-year-old woman, gravida 2 para 1, who presented in early pregnancy with progressive abdominal distension, dyspnea, and hemoconcentration without any history of fertility treatment. Imaging revealed bilateral multicystic ovarian enlargement, significant ascites, and small pleural effusions, while laboratory studies confirmed elevated endogenous human chorionic gonadotropin levels. She was diagnosed with moderate-to-severe spontaneous OHSS and was managed conservatively with intravenous fluids, correction of electrolyte imbalances, thromboprophylaxis, and ultrasound-guided therapeutic paracentesis, leading to gradual clinical improvement. The pregnancy remained viable, and the patient was discharged in stable condition with close follow-up. This case highlights the need for heightened clinical suspicion of spontaneous OHSS in early pregnancy, even in the absence of ovulation induction, as early diagnosis and supportive management are critical for optimizing maternal and fetal outcomes.

Special considerations in assisted reproductive technology for patients with cardiovascular disease

Many individuals with cardiovascular disease can benefit from the availability of assisted reproductive technologies (ARTs) for family building. Its use for this population may be because of underlying infertility, a need for fertility preservation before disease worsening or heart transplant, a genetic cardiac condition they believe to avoid passing to offspring, or the need to use a gestational surrogate in the setting of cardiovascular contraindications to pregnancy. Cardiovascular disease exists on a spectrum, from mild and common diseases that pose minimal threat to maternal health during pregnancy to severe and rare diseases with a high risk of morbidity and maternal mortality if ART or pregnancy is pursued. In this review, we characterize the varying cardiovascular diseases from the lens of the reproductive-aged patient undergoing ART. We classify the necessary steps in the pre-ART evaluation from the multidisciplinary team, discuss risk stratification before ART treatment and possible subsequent pregnancy, and offer specific evidence-based guidance on the care of these patients during the in vitro fertilization and embryo transfer cycles.

Assessing and Addressing Cardiovascular and Obstetric Risks in Patients Undergoing Assisted Reproductive Technology: A Scientific Statement From the American Heart Association

The use of assisted reproductive technology (ART) is growing, both to assist individuals with infertility and for fertility preservation. Individuals with cardiovascular disease (CVD), or risk factors for CVD, are increasingly using ART. Thus, knowing how to care for patients undergoing ART is important for the cardiovascular clinician. In this scientific statement, we review the ART process and known short-term and long-term risks associated with ART that can adversely affect patients with CVD. We review current knowledge on risks from ART for specific cardiac conditions and provide a suggested approach to evaluating and counseling patients with CVD contemplating ART as well as suggested management before and during the ART process. Individuals with CVD are at increased risk for pregnancy complications, and management of this unique population has been discussed previously. The focus of this scientific statement is on ART. Therefore, discussions on risk assessment, counseling, and management of individuals with CVD during pregnancy are limited, and established guidelines are referenced.

A Nomogram Predicting Testicular Sperm Extraction Success in Men With Non-obstructive Azoospermia: A Multi-center Study

OBJECTIVE

To develop an efficient and easy-to-use nomogram that can predict testicular sperm extraction (TESE) success in men with non-obstructive azoospermia (NOA) by using pre-operative parameters.

MATERIALS AND METHODS

Data of 3093 men who underwent TESE for NOA were included in this study. Demographic data, testis volumes, presence of varicocele, length of infertility, history of previous surgeries, history of genitourinary infections, smoking status, chromosome abnormalities, presence of Y-chromosome microdeletion, family history of infertility, testis biopsy, surgical data, sperm retrieval rate, final pathology obtained at TESE, follicle-stimulating hormone, luteinizing hormone, and testosterone levels were recorded. The primary outcome was to develop an efficient nomogram that can predict the TESE success in men with NOA. The secondary outcomes were identifying the significant pre-operative parameters that are associated with success in TESE.

RESULTS

Sperm retrieval rate was 50.2%(1553/3093). Testis volume, history of varicocelectomy, chromosome abnormalities, and presence of Y-chromosome microdeletion were shown to affect sperm retrieval rate significantly (P <.05). Sperm retrieval success was higher in men with older age, higher testis volume (>10 mL), lower follicle-stimulating hormone level (≤12.92 mIU/mL), lower luteinizing hormone level, and higher testosterone level (P <.05). Only testis volume and patient's age were associated with successful sperm retrieval in multivariate logistic regression analysis.

CONCLUSION

In men with NOA, high testis volume, old age, low follicle-stimulating hormone level, low luteinizing hormone level, and high testosterone level are advantageous for successful sperm retrieval in TESE. Herein, we present a nomogram that can predict the outcome of TESE in men with NOA with adequate success.

The Clinical Utility of Measures of Ovarian Reserve

Importance

Measures of ovarian reserve, particularly anti-Müllerian hormone, have been increasingly and inaccurately utilized as "fertility tests." It is important to understand the available measures of ovarian reserve and how to appropriately interpret and integrate their use into clinical practice.

Objectives

The objectives of this article are to review the process of reproductive aging, define ovarian reserve, describe the available measures of ovarian reserve, and discuss the clinical utility of these measures.

Evidence Acquisition

A literature search was performed using the electronic database PubMed. Relevant guidelines, systematic reviews, and original research articles investigating ovarian reserve parameters and their clinical utility were reviewed.

Results

The fecundity of women gradually declines with increasing reproductive age as oocyte quantity and quality decline. Ovarian reserve is defined as the quantity of oocytes remaining in the ovary. Ovarian reserve can be measured indirectly with the use of serum blood tests or ultrasound imaging. Measures of ovarian reserve are clinically useful in several circumstances, particularly for use during fertility treatment and cycles of assisted reproductive technology. However, measures of ovarian reserve are poor predictors of reproductive potential and should not be used as "fertility tests."

Conclusions and Relevance

Measures of ovarian reserve are poor predictors of reproductive potential and should not be used as "fertility tests." Age remains a stronger predictor of reproductive success than measures of ovarian reserve.

The first multiple center prospective study of rhFSH CTP in patients undergoing assisted reproductive technology in China

We assessed the safety and efficacy of rhFSH-CTP, a novel long-acting FSH agent, in controlled ovarian hyperstimulation for patients undergoing ART. A multi-center, open-label, randomized, positive-control, non-inferiority clinical trial was conducted. The study consisted of a phase III randomized design, with a 1:1 ratio favoring the rhFSH-CTP group over the control group. Eligible patients in the rhFSH-CTP group received a single dose of rhFSH-CTP at 100-150 µg for the first 7d of stimulation following a gonadotropin-releasing hormone antagonist protocol. In total, 142 and 141 patients received rhFSH-CTP and rhFSH, respectively. At a confidence interval of 95%, the difference in the number of oocytes (1.13-4.22, 2.67) suggested that rhFSH-CTP was not inferior to rhFSH. Additionally, the top-quality embryos, implantation rates, and pregnancy outcomes were similar between the two groups (P > 0.05). In the rhFSH-CTP group, no cases of severe OHSS were observed, which was a significant improvement compared to the 1.4% incidence in the rhFSH group. With regard to another safety endpoint, no patients tested positive for adenosine deaminase (ADA) in the rhFSH-CTP group. The results demonstrated that the product had a comparable safety profile to pregnancy outcomes and newborn information in the control group, indicating its suitability for use.

Ischemic events are infrequent in patients with ovarian hyperstimulation syndrome

BACKGROUND

Case reports describe arterial thrombosis including ischemic stroke associated with severe ovarian hyperstimulation syndrome (OHSS), but the prevalence of major ischemic events during or shortly after OHSS is unknown.

METHODS

Using publicly available administrative datasets in the United States between 2015 and 2020, we conducted two separate cross-sectional studies of patients with OHSS. We included all patients with OHSS. Our study outcome was any hospitalization for acute ischemic stroke, acute myocardial infarction, cerebral venous sinus thrombosis, pulmonary embolism, or acute deep venous thrombosis during the index hospitalization or within 90 days of OHSS diagnosis.

RESULTS AND CONCLUSIONS

We found very few major ischemic events in patients with OHSS.

Cumulative live birth rate of in vitro fertilization cycle via progestin-primed ovarian stimulation versus gonadotropin-releasing hormone antagonist protocol in infertile women with normal ovarian reserve: an open-label, randomized controlled trial

This study aimed to evaluate the cumulative live birth rate (cLBR) of progestin-primed ovarian stimulation (PPOS) protocol versus gonadotropin-releasing hormone antagonist (GnRH-ant) protocol for in vitro fertilization (IVF) cycle in infertile women with normal ovarian reserve (NOR). Infertile women with NOR who underwent their first IVF cycle were enrolled in an open-label randomized controlled trial. Patients were randomly assigned 1:1 to receive a freeze-all strategy with delayed embryo transfer (PPOS group, n = 174) and fresh embryo transfer first (GnRH-ant group, n = 174). The primary outcome was the cLBR per aspiration. The cLBR between the PPOS group and GnRH-ant group were comparable (55.75% vs. 52.87%, p = 0.591). A premature luteinizing hormone surge was not observed in the PPOS group, while there were six cases (3.45%) in the GnRH-ant group, but no premature ovulation in either of the groups. The pregnancy outcomes, including implantation rate, clinical pregnancy rate and miscarriage rate, were all comparable. In addition, the number of retrieved oocytes, mature oocytes and viable embryos were similar (all p > 0.05) between the two groups.

Risk assessment of patients with underlying health conditions who present for IVF treatment

The increasing number of women with underlying health conditions seeking in vitro fertilization (IVF) necessitates a comprehensive risk assessment framework tailored to their needs. This review aims to provide a practical framework for IVF specialists to systematically assess and manage the risks associated with medically complex patients. The GRASP mnemonic (Genetics, Retrieval, Anaesthetics, Stimulation, Pregnancy) is introduced to facilitate a thorough risk assessment process. The review emphasizes the importance of obtaining detailed medical histories, corroborating information from other healthcare providers, and involving maternal medicine specialists in pre-pregnancy counselling. Furthermore, it highlights the ethical considerations of informed consent, advocating for fertility specialists to take a central role in coordinating care and ensuring patient understanding of risks. Continuous health evaluation throughout the IVF process and clear communication of risks are crucial for improving patient outcomes.

The effect of intravenous calcium gluconate on the prevention of ovarian hyperstimulation syndrome. (A randomized clinical trial)

OBJECTIVE

Oral Cabergoline and intravenous Calcium have the potential to prevent Ovarian Hyperstimulation Syndrome (OHSS) in assisted reproductive technology by regulating the activity of the Vascular Endothelial Growth Factor (VEGF) receptor. The purpose of this study was to examine the effect of Cabergoline with intravenous Calcium versus oral Cabergoline alone on the overall rate of OHSS.

METHODS

This study is a randomized clinical trial which was carried out in Milad Infertility Center affiliated with Mashhad University of Medical Sciences, Mashhad, Iran between April 2016 and January 2018. A total of 192 patients were randomly assigned into two groups. The control group received oral Cabergoline and the intervention group received Calcium gluconate in addition to Cabergoline. A total rate of OHSS, moderate and severe OHSS were measured in both groups.

RESULTS

The demographic characteristics of the participants and the types of drugs used showed homogeneity between the intervention and control groups (P > 0.05). Furthermore, there was no significant difference between the two groups in terms of the number of the follicle, oocytes obtained, metaphase II oocytes, the number of embryos, and the rate of fertilization. Regarding the incidence of OHSS, 26.2 % of participants in the control group experienced OHSS, while the occurrence rate was 15.7 % in the intervention group (P = 0.401). The incidence of severe OHSS in the control group and intervention group was 7.1 % and 3.6 %, respectively.

CONCLUSION

Intravenous injection of Calcium gluconate can be effective in preventing Ovarian Hyperstimulation Syndrome.

Efficacy of acupuncture for pregnancy with early-onset ovarian hyperstimulation syndrome: study protocol for a randomised controlled clinical trial

INTRODUCTION

Although ovarian hyperstimulation syndrome (OHSS) is a common complication primarily seen in patients undergoing in vitro fertilisation-embryo transfer, there is no recognised effective treatment to manage it, especially for pregnant patients. As an alternative non-pharmacological treatment, acupuncture presents itself as a promising, safe and effective intervention for those suffering from OHSS. Despite its potential, there is a noticeable absence of randomised controlled trials providing solid evidence on the efficacy of acupuncture in the management of pregnancy with OHSS. Therefore, the primary objective of this study is to conduct an initial investigation into the efficacy of acupuncture in pregnant patients with OHSS, hoping to contribute valuable insights from a medical-scientific perspective.

METHODS AND ANALYSIS

This is a three-arm, single-blind, parallel-design, randomised controlled clinical trial. A total of 384 patients will be enrolled and randomised in a ratio of 1:1:1 into acupuncture group (MA group), sham acupuncture group (SA group) and control group (C group) for a 20-day treatment period. The primary outcomes include 24-hour urine output, amount of ascites shown on ultrasound, abdominal circumference, degree of abdominal distension and chest tightness. The secondary outcomes are weight, ovarian size, rate of ascites drainage by tube placement and serum hCG. Besides, the study will consider changes in blood counts and hormonal levels as additional outcomes.

ETHICS AND DISSEMINATION

This study received authorisation from the Institutional Review Board of the Sixth Affiliated Hospital of Sun Yat-sen University on 4 February 2024 (Approval No. 2024ZSLYFEC-084). Study findings will be disseminated through presentations at scientific conferences or publications in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry ChiCTR2400081751.

[Experiences of Unmarried Women Undergoing Planned Oocyte Cryopreservation]

PURPOSE

The present study investigated the experiences of unmarried women undergoing planned oocyte cryopreservation (OC).

METHODS

Data were collected from August 2022 to February 2023 through individual in-depth interviews with thirteen unmarried women undergoing planned OC. Data were analyzed using Colazzi's phenomenological method.

RESULTS

The findings revealed four distinct clusters. The first cluster, "Safeguards against Future Uncertainty," examined experiences associated with uncertainties in several aspects of reproductive health threats and decision-making regarding planned OC. The second cluster, "Indescribable Pain and Chaos," explored the psychological and physical pain, complications, concerns about repeat procedures, and uncertainties about the use of frozen oocytes experienced during the planned OC process and afterward. The third cluster, "Motivation to Rebuild Resilience," explored participants' resilience in overcoming difficulties and shocks during the planned OC process and regaining their inner strength through the support of family and friends. The fourth cluster, "Finally Freeing the Mind," focused on the sense of liberation from the pressure of marriage and childbirth, which enabled participants to engage in their present self and concentrate on self-stability and growth in preparation for the future.

CONCLUSION

The present study enhances our understanding of the emotional difficulties and distress experienced by women considering OC, thereby assisting in improving approaches for psychological support and clinical management. Furthermore, providing insights into these first-hand experiences to women considering planned OC, healthcare professionals, and policymakers could help establish systems to support the decision-making process.

Estradiol-to-follicle ratio on human chorionic gonadotropin day is a novel predictor of gestational diabetes mellitus in women receiving fresh embryo transfer

Aims

To assess the predictive value of estradiol (E2) related parameters on the incidence of gestational diabetes mellitus (GDM) in women undergoing fresh embryo transfer.

Materials and methods

A Post-hoc analysis of a prospective cohort study.

Results

We identified an optimal E2/follicle (E2/F) ratio threshold of 246.03 pg/ml on the day of human chorionic gonadotropin (hCG) administration. Women with an E2/F ratio exceeding this threshold had significantly lower rates of GDM (12.75% vs. 20.41%, P < 0.001) and ovarian hyperstimulation syndrome (OHSS) (11.75% vs. 15.48%, P = 0.03). Additional E2 parameters were also evaluated: baseline E2, E2 on hCG day, E2 increase, and E2 fold change. Lower GDM rates were observed in women with baseline E2 above 31.50 pg/ml (13.51% vs. 19.42%, P <0.01), E2 on hCG day above 3794.50 pg/ml (12.26% vs. 19.32%, P < 0.001), and E2 increase above 3771.50 pg/ml (12.24% vs. 19.28%, P < 0.001). There were no significant differences in OHSS rates for these additional E2 parameters. After adjusting for confounders, lower E2/F ratio (OR: 1.626, 95% CI: 1.229-2.150, P <0.01), E2 on hCG day (OR: 1.511, 95% CI: 1.133-2.016, P = 0.01), and E2 increase (OR: 1.522, 95% CI: 1.141-2.031, P <0.01) were identified as risk factors for GDM.

Conclusion

This study demonstrates that an E2/F ratio over 246.03 pg/ml is significantly associated with a reduced risk of both GDM and OHSS in women undergoing fresh embryo transfer, highlighting the E2/F ratio as a superior predictive biomarker compared to other E2-related parameters.

Optimized personalized management approach for moderate/severe OHSS: development and prospective validation of an OHSS risk assessment index

STUDY QUESTION

Can a simplified ovarian hyperstimulation syndrome (OHSS) risk assessment index be developed and validated with sufficient discrimination of moderate/severe OHSS from those without OHSS?

SUMMARY ANSWER

This easy-to-use OHSS risk assessment index shows good discriminative power and high calibration accuracy in internal and external validation cohorts.

WHAT IS KNOWN ALREADY

An early alert and risk stratification is critical to prevent the occurrence of OHSS. We have previously developed a multi-stage smartphone app-based prediction model to evaluate the risk of OHSS, but app use might not be so convenient in many primary institutions. A simplified OHSS risk assessment index has been required.

STUDY DESIGN, SIZE, DURATION

This training and internal validation of an OHSS risk assessment index used retrospective cohort data from January 2016 to December 2020. External validation was performed with a prospective cohort database from January 2021 to May 2022. There were 15 066 cycles in the training cohort, 6502 cycles in the internal validation cohort, and 8097 cycles in the external validation cohort.

PARTICIPANTS/MATERIALS, SETTING, METHODS

This study was performed in the reproductive medicine center of a tertiary hospital. Infertile women who underwent ovarian stimulation were included. Data were extracted from the local database with detailed medical records. A multi-stage risk assessment index was constructed at multiple stages. The first stage was before the initiation of ovarian stimulation, the second was before the ovulation trigger, the third was after oocyte retrieval, and the last stage was on the embryo transfer day if fresh embryo transfer was scheduled.

MAIN RESULTS AND THE ROLE OF CHANCE

We established a simplified multi-stage risk assessment index for moderate/severe OHSS, the performance of which was further evaluated with discrimination and calibration abilities in training and internal and external validation cohorts. The discrimination abilities of the OHSS risk assessment index were determined with C-statistics. C-statistics in training (Stages 1-4: 0.631, 0.692, 0.751, 0.788, respectively) and internal (Stages 1-4: 0.626, 0.642, 0.755, 0.771, respectively) and external validation (Stages 1-4: 0.668, 0.670, 0.754, 0.773, respectively) cohorts were all increased from Stage 1 to 3 with similar trends, and were comparable between Stages 3 and 4. Calibration plots showed high agreement between observed and predicted cases in all three cohorts. Incidences of OHSS based on diverse risk stratification (negligible risk, low risk, medium risk, and high risk) were 0%, 0.6%, 2.7%, and 8.3% in the training cohort, 0%, 0.6%, 3.3%, and 8.5% in the internal validation cohort, and 0.1%, 1.1%, 4.1%, and 7.2% in the external validation cohort.

LIMITATIONS, REASONS FOR CAUTION

The influence from clinical interventions including cryopreservation of all embryos cannot be eliminated and thus certain risk factors like estrogen level on trigger day might be assigned with a lower risk score. Another weakness of the study is that several preventive treatments, for instance oral aspirin and letrozole, were not recorded and evaluated in the model. Despite the robust reliability of OHSS assessment index, this tool cannot be used directly for clinical decision-making or as a diagnostic tool. Its value lies in its capacity to evaluate the prognosis of various interventions and to facilitate clinician-patient communication. The combination of this tool and further symptoms and examinations should be all taken into consideration for accurate and personalized management of OHSS.

WIDER IMPLICATIONS OF THE FINDINGS

The OHSS risk assessment index can be implemented to facilitate personalized counseling and management of OHSS.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by National Key R&D Program of China (2022YFC2702504), Medical Research Fund Guangdong Provincial (A2024003), and Xinjiang Support Rural Science and Technology (Special Correspondent) Program in Guangdong Province (KTPYJ 2023014). All authors had nothing to disclose.

TRIAL REGISTRATION NUMBER

N/A.

Individualized dosing of follitropin delta affects live birth and safety in in vitro fertilization treatment: an individual participant data meta-analysis of randomized controlled trials

OBJECTIVE

To undertake a one-stage meta-analysis of individual patient data from randomized trials comparing individualized dosing of follitropin delta vs. other forms of follitropin (alpha and beta) for live birth (LB) rates (LBR) and safety parameters in women undergoing ovarian stimulation for in vitro fertilization treatment.

DESIGN

Systematic review with individual patient data meta-analysis.

SETTING

Not applicable.

PATIENTS

Women undergoing ovarian stimulation for in vitro fertilization treatment.

INTERVENTIONS

We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the Web of Science to identify eligible phase 3 trials between January 1, 2000, and February 1, 2023.

MAIN OUTCOME MEASURES

All analyses were based on individual participant data. We used a general linear mixed effects logistic regression model using fixed effects for treatment drugs interacting with log (AMH) level, age, and random effects for country and trial to compare the primary efficacy and safety outcomes of LB and early ovarian hyperstimulation syndrome (OHSS) and/or the need for OHSS preventative measures, with ovarian stimulation parameters and neonatal outcomes also assessed. PROSPERO registration: CRD42023399711.

RESULTS

Three trials met inclusion criteria and included 2,685 women undertaking 2,682 cycles between October 2013 and May 2020, with LB follow-up through to February 1, 2023. For women with an elevated AMH level (≥15 pmol/L), there was high-quality evidence that the use of individualized dosing of follitropin delta was associated with an increased LB rate (adjusted odds ratio [adj OR] 1.64, 95% confidence interval [CI] 1.14, 2.36). Safety outcomes were also improved with a reduced risk of both early OHSS and/or the need for preventative interventions (adj OR 0.27, 95% CI 0.15, 0.49) and early moderate or severe OHSS (adj OR 0.30, 95% CI 0.16, 0.58). These improvements in outcomes were obtained with a lower total dose of gonadotropin (-48.7 μg, 95% CI -53.7, -43.8) and no adjustments in the daily dose. In contrast, similar LB rates (adj OR 0.86, 95% CI 0.63, 1.17) and safety outcomes (adj OR 1.92, 95% CI 0.76, 4.87) were observed for women with an AMH level of <15 pmol/L. There were no clinically meaningful differences in neonatal outcomes.

CONCLUSION

Using follitropin delta in an AMH level and weight-based algorithm rather than conventional licensed dosing of follitropin alpha or beta for ovarian stimulation in women is associated with improved LB rates and safety outcomes for women with elevated AMH levels.

Ovarian Hyperstimulation Syndrome (OHSS): A Narrative Review and Legal Implications

BACKGROUND

Infertility is a highly meaningful issue with potentially life-changing consequences, and its incidence has been growing worldwide. Assisted reproductive technology (ART) has made giant strides in terms of treating many infertility conditions, despite the risk of developing ovarian hyperstimulation syndrome (OHSS), a potentially life-threatening complication.

METHODS

This narrative review draws upon scientific articles found in the PubMed database. The search spanned the 1990-2024 period. Search strings used included "OHSS" or "ovarian hyperstimulation" and "IVF" and "GnRH" and "hCG"; 1098 results were retrieved and were ultimately narrowed down to 111 suitable sources, i.e., relevant articles dealing with the condition's underlying dynamics, management pathways, and evidence-based criteria and guidelines, crucial both from a clinical perspective and from the standpoint of medicolegal tenability.

RESULTS

The following features constitute OHSS risk factors: young age, low body weight, and polycystic ovarian syndrome (PCOS), among others. GnRH antagonist can substantially lower the risk of severe OHSS, compared to the long protocol with a gonadotropin-releasing hormone (GnRH) agonist. However, a mild or moderate form of OHSS is also possible if the antagonist protocol is used, especially when hCG is used for the final maturation of oocytes. For women at risk of OHSS, GnRH agonist trigger and the freeze-all strategy is advisable. OHSS is one of the most frequent complications, with a 30% rate in IVF cycles.

CONCLUSION

Providing effective care for OHSS patients begins with early diagnosis, while also evaluating for comorbidities and complications. In addition to that, we should pay more attention to the psychological component of this complication and of infertility as a whole. Compliance with guidelines and evidence-based best practices is essential for medicolegal tenability.

Albumin: a comprehensive review and practical guideline for clinical use

PURPOSE

Nowadays, it is largely accepted that albumin should not be used in hypoalbuminemia or for nutritional purpose. The most discussed indication of albumin at present is the resuscitation in shock states, especially distributive shocks such as septic shock. The main evidence-based indication is also liver disease. In this review, we provided updated evidence-based instruction for definite and potential indications of albumin administration in clinical practice, with appropriate dosing and duration.

METHODS

Data collection was carried out until November 2023 by search of electronic databases including PubMed, Google Scholar, Scopus, and Web of Science. GRADE system has been used to determine the quality of evidence and strength of recommendations for each albumin indication.

RESULTS

A total of 165 relevant studies were included in this review. Fluid replacement in plasmapheresis and liver diseases, including hepatorenal syndrome, spontaneous bacterial peritonitis, and large-volume paracentesis, have a moderate to high quality of evidence and a strong recommendation for administering albumin. Moreover, albumin is used as a second-line and adjunctive to crystalloids for fluid resuscitation in hypovolemic shock, sepsis and septic shock, severe burns, toxic epidermal necrolysis, intradialytic hypotension, ovarian hyperstimulation syndrome, major surgery, non-traumatic brain injury, extracorporeal membrane oxygenation, acute respiratory distress syndrome, and severe and refractory edema with hypoalbuminemia has a low to moderate quality of evidence and weak recommendation to use. Also, in modest volume paracentesis, severe hyponatremia in cirrhosis has a low to moderate quality of evidence and a weak recommendation.

CONCLUSION

Albumin administration is most indicated in management of cirrhosis complications. Fluid resuscitation or treatment of severe and refractory edema, especially in patients with hypoalbuminemia and not responding to other treatments, is another rational use for albumin. Implementation of evidence-based guidelines in hospitals can be an effective measure to reduce inappropriate uses of albumin.

Assessment of active translation in cumulus-enclosed and denuded oocytes during standard in vitro maturation and early embryo development

STUDY QUESTION

Which actively translated maternal transcripts are differentially regulated between clinically relevant in vitro and in vivo maturation (IVM) conditions in mouse oocytes and zygotes?

SUMMARY ANSWER

Our findings uncovered significant differences in the global transcriptome as well as alterations in the translation of specific transcripts encoding components of energy production, cell cycle regulation, and protein synthesis in oocytes and RNA metabolism in zygotes.

WHAT IS KNOWN ALREADY

Properly regulated translation of stored maternal transcripts is a crucial factor for successful development of oocytes and early embryos, particularly due to the transcriptionally silent phase of meiosis.

STUDY DESIGN, SIZE, DURATION

This is a basic science study utilizing an ICR mouse model, best suited for studying in vivo maturation. In the treatment group, fully grown germinal vesicle oocytes from stimulated ovaries were in vitro matured to the metaphase II (MII) stage either as denuded without gonadotropins (IVM DO), or as cumulus-oocyte complexes (IVM COC) in the presence of 0.075 IU/ml recombinant FSH (rFSH) and 0.075 IU/ml recombinant hCG (rhCG). To account for changes in developmental competence, IVM COC from non-stimulated ovaries (IVM COC-) were included. In vivo matured MII oocytes (IVO) from stimulated ovaries were used as a control after ovulation triggering with rhCG. To simulate standard IVM conditions, we supplemented media with amino acids, vitamins, and bovine serum albumin. Accordingly, in vitro pronuclear zygotes (IMZ) were generated by IVF from IVM DO, and were compared to in vivo pronuclear zygotes (IVZ). All experiments were performed in quadruplicates with samples collected for both polyribosome fractionation and total transcriptome analysis. Samples were collected over three consecutive months.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All ICR mice were bred under legal permission for animal experimentation (no. MZE-24154/2021-18134) obtained from the Ministry of Agriculture of the Czech Republic. Actively translated (polyribosome occupied) maternal transcripts were detected in in vitro and in vivo matured mouse oocytes and zygotes by density gradient ultracentrifugation, followed by RNA isolation and high-throughput RNA sequencing. Bioinformatic analysis was performed and subsequent data validation was done by western blotting, radioactive isotope, and mitotracker dye labelling.

MAIN RESULTS AND THE ROLE OF CHANCE

Gene expression analysis of acquired polysome-derived high-throughput RNA sequencing data revealed significant changes (RPKM ≥ 0.2; P ≤ 0.005) in translation between in vitro and in vivo matured oocytes and respectively produced pronuclear zygotes. Surprisingly, the comparison between IVM DO and IVM COC RNA-seq data of both fractionated and total transcriptome showed very few transcripts with more than a 2-fold difference. Data validation by radioactive isotope labelling revealed a decrease in global translation bof20% in IVM DO and COC samples in comparison to IVO samples. Moreover, IVM conditions compromised oocyte energy metabolism, which was demonstrated by both changes in polysome recruitment of each of 13 mt-protein-coding transcripts as well as by validation using mitotracker red staining.

LARGE SCALE DATA

The data discussed in this publication have been deposited in NCBI's Gene Expression Omnibus and are accessible through GEO Series accession number GSE241633 (https://www.ncbi.nlm.nih.gov/geo/query/acc.cgi?acc=GSE241633).

LIMITATIONS, REASONS FOR CAUTION

It is extremely complicated to achieve in vivo consistency in animal model systems such as porcine or bovine. To achieve a high reproducibility of in vivo stimulations, the ICR mouse model was selected. However, careful interpretation of our findings with regard to assisted reproductive techniques has to be made by taking into consideration intra-species differences between the mouse model and humans. Also, the sole effect of the cumulus cells' contribution could not be adequately addressed by comparing IVM COC and IVM DO, because the IVM DO were matured without gonadotropin supplementation.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings confirmed the inferiority of standard IVM technology compared with the in vivo approach. It also pointed at compromised biological processes employed in the critical translational regulation of in vitro matured MII oocytes and pronuclear zygotes. By highlighting the importance of proper translational regulation during in vitro oocyte maturation, this study should prompt further clinical investigations in the context of translation.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the Czech Grant Agency (22-27301S), Charles University Grant Agency (372621), Ministry of Education, Youth and Sports (EXCELLENCE CZ.02.1.01/0.0/0.0/15_003/0000460 OP RDE), and Institutional Research Concept RVO67985904. No competing interest is declared.

Acute Lymphoblastic Leukemia in Pregnant Ovarian Hypersensitivity Syndrome

ABSTRACT

Ovarian hyperstimulation syndrome (OHSS) is characterized by cystic enlargement of the ovaries and a fluid retention. This syndrome is sometimes caused after in vitro fertilization. We treated a 37-year-old woman with OHSS after in vitro fertilization, coincidentally complicated with acute lymphoblastic leukemia. Her clinical course of acute lymphoblastic leukemia was aggressive with the manifestation of OHSS, such as massive pleural effusion and massive ascites. The leukemic cells broadly infiltrated to the peritoneum, ovary, central spine fluid, and pleura. We speculated that this hyperpermeability of leukemic cells could be associated with the cytokine milieu caused by OHSS.

Effect of aromatase inhibitors for preventing ovarian hyperstimulation syndrome in infertile patients undergoing in vitro fertilization: a systematic review and meta-analysis

PURPOSE

To summarize the findings of relevant randomized controlled trials (RCTs) and conduct a meta-analysis to investigate the potential effect of aromatase inhibitors on preventing moderate to severe ovarian hyperstimulation syndrome (OHSS) in infertile women undergoing in vitro fertilization (IVF).

METHODS

We searched for relevant RCTs in electronic databases, including MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov (from inception to August 2023). In addition, we manually searched the related reviews and reference lists of included studies for further relevant studies. We included RCTs where aromatase inhibitors prescribed either during controlled ovarian stimulation (COS) or in early luteal phase. The meta-analysis was performed using RevMan 5.4.1 software. The primary outcome was the incidence of moderate to severe OHSS. A descriptive analysis was conducted in cases where a meta-analysis was not feasible due to heterogeneity or lack of comparable data.

RESULTS

2858 records were retrieved and 12 RCTs were finally included. Letrozole was administered in the treatment group during COS in seven RCTs, whereas in the early luteal phase in five RCTs. Compared with the control group, the risk of moderate to severe OHSS significantly reduced by 55% in the letrozole group (RR 0.45, 95% CI 0.32 to 0.64, I2 = 0%, 5 RCTs, 494 patients). Moreover, serum estradiol (E2) levels on hCG trigger day significantly decreased with the administration of letrozole during COS (MD -847.23, 95% CI -1398.00 to -296.47, I2 = 93%, 5 RCTs, 374 patients). And serum E2 levels on the 4th, 5th and 7th to 10th day after hCG trigger were also significantly lower than those in the control group when letrozole was administered in the early luteal phase.

CONCLUSIONS

Patients with high risk of OHSS probably benefit from letrozole, which has been revealed to reduce the incidence of moderate to severe OHSS by this systematic review. However, the very limited number of participants and the quality of the included studies does not allow to recommend letrozole for the prevention of severe OHSS.

Fertility treatment for people with epilepsy

Fertility treatment, including assisted reproductive technology (ART), is increasingly used. Sex hormones influence seizure control as well as interacting with antiseizure medications, and so the hormonal manipulation involved in fertility treatments has direct implications for people with epilepsy. Here, we summarise the various fertility treatments and consider their important influences on epilepsy care. While early observations raised concerns about seizure exacerbation associated with ART, there are limited data to guide best practice in people with epilepsy, and further research is needed.

Comparison of HCG Trigger versus Dual Trigger in Improving Pregnancy Outcomes in Patients with Different Ovarian Responses: A Retrospective Study

Objective

During in vitro fertilization-embryo transfer (IVF-ET) treatment, the reproductive endocrine regulatory mechanisms hold pivotal importance. Specifically, the serum estradiol (E 2) level during ovulation emerges as a critical factor influencing pregnancy outcomes. This retrospective study aimed to comprehensively compare two common clinical regimens based on the grouping of serum E 2 levels and the number of oocytes retrieved on the trigger day. Our objective was to evaluate the pregnancy outcomes in IVF-ET patients across different ovarian response groups, exploring the efficacy of the dual-trigger and single-trigger regimens to provide valuable insights for optimizing clinical strategies in the context of IVF-ET.

Methods

A retrospective analysis was conducted on the clinical data of 2778 infertile patients who underwent ART (IVF/ICSI). Subsequently, a detailed statistical analysis was performed on 1032 patients following an antagonist regimen. Participants were categorized into single-trigger and dual-trigger groups based on real-world trigger protocols, considering different ovarian responses. Comprehensive statistical assessments were conducted on baseline characteristics, ovulation induction, and pregnancy outcomes.

Results

Baseline characteristics and cycle parameters among the three patient groups (high ovarian response, normal response, and poor response) exhibited no significant differences between the dual-trigger and single-trigger regimen groups. Despite the dual-trigger regimen utilizing a significantly lower HCG dose, no notable discrepancies were observed in laboratory results and pregnancy outcomes (embryo transfer rate, pregnancy rate, and live birth rate) for normal and high responders. Remarkably, E 2 levels were higher in the dual-trigger group compared to the single-trigger group. In high and normal responders, the dual-trigger regimen demonstrated increased oocyte counts and oocyte acquisition rates, coupled with decreased transfer cancellation rates attributed to ovarian hyperstimulation syndrome (OHSS). Intriguingly, patients with a poor ovarian response experienced no graft cancellations due to OHSS prevention in either group.

Conclusion

For patients with high and normal ovarian responses, the utilization of a dual-trigger regimen on the trigger day effectively mitigates the risk of OHSS. Our large sample study supports the substitutability of the dual-trigger regimen over the single-trigger regimen without compromising pregnancy outcomes. However, this conclusion is not applicable to patients with poor ovarian responses. The results of this study highlight the necessity of adopting a customized and individualized treatment approach that should be based on the patient's ovarian response. Additionally, recognizing the pivotal role of the endocrine environment in influencing pregnancy outcomes and the occurrence of OHSS, further exploration of the effects of different triggering regimens on endocrine parameters is warranted. Such investigations will contribute to enhancing the reproductive outcomes of IVF-ET technology.

Risk factors for poor oocyte yield and oocyte immaturity after GnRH agonist triggering

STUDY QUESTION

What are the potential risk factors for poor oocyte recuperation rate (ORR) and oocyte immaturity after GnRH agonist (GnRHa) ovulation triggering?

SUMMARY ANSWER

Lower ovarian reserve and LH levels after GnRHa triggering are risk factors of poor ORR. Higher BMI and anti-Müllerian hormone (AMH) levels are risk factors of poor oocyte maturation rate (OMR).

WHAT IS KNOWN ALREADY

The use of GnRHa to trigger ovulation is increasing. However, some patients may have a suboptimal response after GnRHa triggering. This suboptimal response can refer to any negative endpoint, such as suboptimal oocyte recovery, oocyte immaturity, or empty follicle syndrome. For some authors, a suboptimal response to GnRHa triggering refers to a suboptimal LH and/or progesterone level following triggering. Several studies have investigated a combination of demographic, clinical, and endocrine characteristics at different stages of the treatment process that may affect the efficacy of the GnRHa trigger and thus be involved in a poor endocrine response or efficiency but no consensus exists.

STUDY DESIGN, SIZE, DURATION

Bicentric retrospective cohort study between 2015 and 2021 (N = 1747).

PARTICIPANTS/MATERIALS, SETTING, METHODS

All patients aged 18-43 years who underwent controlled ovarian hyperstimulation and ovulation triggering by GnRHa alone (triptorelin 0.2 mg) for ICSI or oocyte cryopreservation were included. The ORR was defined as the ratio of the total number of retrieved oocytes to the number of follicles >12 mm on the day of triggering. The OMR was defined as the ratio of the number of mature oocytes to the number of retrieved oocytes. A logistic regression model with a backward selection method was used for the analysis of risk factors. Odds ratios (OR) are displayed with their two-sided 95% confidence interval.

MAIN RESULTS AND THE ROLE OF CHANCE

In the multivariate analysis, initial antral follicular count and LH level 12-h post-triggering were negatively associated with poor ORR (i.e. below the 10th percentile) (OR: 0.61 [95% CI: 0.42-0.88]; P = 0.008 and OR: 0.86 [95% CI: 0.76-0.97]; P = 0.02, respectively). A nonlinear relationship was found between LH level 12-h post-triggering and poor ORR, but no LH threshold was found. A total of 25.3% of patients suffered from oocyte immaturity (i.e. OMR < 75%). In the multivariate analysis, BMI and AMH levels were negatively associated with an OMR < 75% (OR: 4.34 [95% CI: 1.96-9.6]; P < 0.001 and OR: 1.22 [95% CI: 1.03-1.12]; P = 0.015, respectively). Antigonadotrophic pretreatment decreased the risk of OMR < 75% compared to no pretreatment (OR: 0.72 [95% CI: 0.57-0.91]; P = 0.02).

LIMITATIONS, REASONS FOR CAUTION

Our study is limited by its retrospective design and by the exclusion of patients who had hCG retriggers. However, this occurred in only six cycles. We were also not able to collect information on the duration of pretreatment and the duration of wash out period.

WIDER IMPLICATIONS OF THE FINDINGS

In clinical practice, to avoid poor ORR, GnRHa trigger alone should not be considered in patients with higher BMI and/or low ovarian reserve, balanced by the risk of ovarian hyperstimulation syndrome. In the case of a low 12-h post-triggering LH level, practicians must be aware of the risk of poor ORR, and hCG retriggering could be considered.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

N/A.

Comparison between oral dydrogesterone versus micronized vaginal progesterone gel in clinical outcome within the first HRT-FET cycle: a retrospective analysis

OBJECTIVE

The purpose of this study is to compare the clinical efficacy of oral dydrogesterone and micronized vaginal progesterone (MVP) gel during the first HRT-FET cycle.

METHODS

A retrospective cohort study based on a total of 344 women undergoing their first HRT-FET cycles without Gonadotropin-Releasing Hormone agonist (GnRH-a) pretreatment was conducted. All the cycles were allocated to two groups in the reproductive medical center at the University of Hong Kong-Shenzhen Hospital. One group (n = 193) received oral dydrogesterone 30 mg/d before embryo transfer, while the other group (n = 151) received MVP gel 180 mg/d.

RESULTS

The demographics and baseline characteristics of two groups were comparable. We found no statistically significant difference in live birth rate (24.35% vs. 31.13%, P = 0.16), clinical pregnancy rate (34.72% vs. 36.42%, P = 0.74), embryo implantation rate (25.09% vs. 28.36%, P = 0.43), positive pregnancy rate (42.49% vs 38.41%, P = 0.45), miscarriage rate (9.33% vs 3.97%, P = 0.05), or ectopic pregnancy rate (0.52% vs. 0.66%, P = 0.86) between the oral dydrogesterone group and MVP gel group. In the multivariate logistic regression analysis for covariates, medication used for luteal support was not associated with live birth rate (OR = 0.73, 95% CI: 0.32-1.57, P = 0.45). And the different luteal support medication did not have a significant positive association with the live birth rate in the cycles with day 2 embryo transferred (OR = 1.39, 95% CI:0.66-2.39, P = 0.39) and blastocyst transferred (OR = 1.31 95% CI:0.64-2.69, P = 0.46).

CONCLUSION

30 mg/d oral dydrogesterone and 180 mg/d MVP gel revealed similar reproductive outcomes in HRT-FET cycles in the study.

Fertility Preservation in the Era of Immuno-Oncology: Lights and Shadows

In recent years, immuno-oncology has revolutionized the cancer treatment field by harnessing the immune system's power to counteract cancer cells. While this innovative approach holds great promise for improving cancer outcomes, it also raises important considerations related to fertility and reproductive toxicity. In fact, most young females receiving gonadotoxic anti-cancer treatments undergo iatrogenic ovarian exhaustion, resulting in a permanent illness that precludes the vocation of motherhood as a natural female sexual identity. Although commonly used, oocyte cryopreservation for future in vitro fertilization and even ovarian cortex transplantation are considered unsafe procedures in cancer patients due to their oncogenic risks; whereas, ovarian stem cells might support neo-oogenesis, providing a novel stemness model of regenerative medicine for future fertility preservation programs in oncology. Recent scientific evidence has postulated that immune checkpoint inhibitors (ICIs) might in some way reduce fertility by inducing either primary or secondary hypogonadism, whose incidence and mechanisms are not yet known. Therefore, considering the lack of data, it is currently not possible to define the most suitable FP procedure for young patients who are candidates for ICIs. In this report, we will investigate the few available data concerning the molecular regulation of ICI therapy and their resulting gonadal toxicity, to hypothesize the most suitable fertility preservation strategy for patients receiving these drugs.

Pretreatment with oral contraceptive pills in women with PCOS scheduled for IVF: a randomized clinical trial

STUDY QUESTION

What is the effect of pretreatment with oral contraceptive pills (OCPs) on oocyte and embryo quality and pregnancy rates in women with polycystic ovary syndrome (PCOS) scheduled for IVF/ICSI cycles?

SUMMARY ANSWER

In women with PCOS who underwent a first or second IVF/ICSI cycle with a GnRH antagonist protocol and were randomized to start ovarian stimulation immediately, the quality of cleavage-stage embryos was non-inferior to pretreatment with OCP.

WHAT IS KNOWN ALREADY

PCOS in Asian populations is characterized by high levels of circulating LH in the early follicular phase. Previous studies indicated that inappropriately high LH levels might affect oocyte maturation and fertilization rates, and impaired embryo quality, consequently resulting in higher rates of impaired pregnancy and miscarriage in women with PCOS. OCPs are frequently used as pretreatment to lower LH levels in PCOS patients.

STUDY DESIGN SIZE DURATION

We performed a randomized controlled trial. After informed consent, women diagnosed with PCOS scheduled for their first or second IVF/ICSI cycle with a GnRH antagonist protocol were randomized to receive OCPs (OCP group) or start ovarian stimulation immediately, regardless of the day of the menstrual cycle (non-OCP group). Using a non-inferiority hypothesis, the sample size was calculated at 242 women. The study lasted from 7 February 2018 to 31 August 2021.

PARTICIPANTS/MATERIALS SETTING METHODS

A total of 242 infertility patients with PCOS undergoing the first or second cycle of IVF or ICSI were enrolled and randomized into two groups. In the OCP group, recombinant FSH was started on Day 7 of the washout period after pretreatment with OCP. In the non-OCP group, recombinant FSH was started immediately regardless of the day of the menstrual cycle. All participants received standardized GnRH antagonist ovarian stimulation. The freeze-all strategy was applied to all participants. The primary outcome was the number of good-quality embryos on Day 3 after insemination. Secondary outcomes included the rates of blastocyst formation, implantation, clinical pregnancy, and live birth from the first frozen/warmed embryo transfer cycles and cumulative live birth rates.

MAIN RESULTS AND THE ROLE OF CHANCE

We randomized 242 women to receive OCP (n = 121) or start immediately with ovarian stimulation (n = 121). The number of good-quality embryos on Day 3 in the OCP group was non-inferior to the non-OCP group (OCP group versus non-OCP group, 6.58 ± 4.93 versus 7.18 ± 4.39, AD -0.61, 95% CI: -1.86 to 0.65, P = 0.34). The rates of blastocyst formation (55.4% versus 52.9%, relative risk (RR) 1.11, 95% CI: 0.96 to 1.28, P = 0.17), implantation (63.0% versus 65.5%, RR 0.90, 95% CI: 0.53 to 1.53, P = 0.79), clinical pregnancy (67.9% versus 68.8%, RR 0.96, 95% CI: 0.54 to 1.71, P = 1.0), and live birth rate (52.8% versus 55.1%, RR 0.92, 95% CI: 0.53 to 1.56, P = 0.79) of the first frozen/warmed embryo transfer cycles were all comparable between the OCP and non-OCP group, respectively. Cumulative live birth rates were also similar in the OCP and non-OCP groups (78.3% versus 83.5%, respectively RR 0.71, 95% CI: 0.36 to 1.42, P = 0.39).

LIMITATIONS REASONS FOR CAUTION

Only patients with PCOS in Southern China were recruited. Therefore, caution is necessary when generalizing our results to all such patients with PCOS. Also, since a freeze-only strategy was used, the results of this study are only applicable when infertile women with PCOS undergo the freeze-only method. The obvious treatment difference between the two groups meant that the study was designed as an open-label study for women and doctors. The study had a randomized controlled design that minimized bias.

WIDER IMPLICATIONS OF THE FINDINGS

Pretreatment with OCPs to lower LH levels in patients with PCOS before ovarian stimulation in IVF or ICSI cycles may not improve the quality of cleavage-stage embryos.

STUDY FUNDING/COMPETING INTERESTS

This study was funded by the National Key Research and Development Program of China (No. 2023YFC2705503). This study was supported in part by the Investigator-Initiated Studies Program (grant from MSD and Organon). BWM reports consultancy, travel support, and research funding from Merck. He reports consultancy from Organon and Norgine, and also reports holding stock from ObsEva. No conflicts of interest are declared for the other authors.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (No. chiCTR1800014822). URL: https://www.chictr.org.cn/showproj.html?proj=25280.

TRIAL REGISTRATION DATE

7 February 2018.

DATE OF FIRST PATIENT’S ENROLLMENT

22 February 2018.

Efficacy of Dan'e Fukang Soft Extract in Moderate Ovarian Hyperstimulation Syndrome for Concurrent Treatment of Blood and Fluid Guided by the "Triple Prevention" Principle

Objective

This study aimed to evaluate the therapeutic efficacy and safety of Dan'e Fukang soft extracts in moderate ovarian hyperstimulation syndrome (OHSS) for the simultaneous treatment of blood and fluid, guided by the traditional Chinese medicine principle of "triple prevention".

Methods

This study conducted a retrospective analysis of clinical data from outpatients who underwent in vitro fertilization (IVF)/intracytoplasmic sperm injection embryo transfer (ICSI-ET). A total of 2245 cases were included and divided into a treatment group (1002 cases) and a control group (1243 cases). Patients in the treatment group were administered Dan'e Fukang soft extracts orally in addition to conventional Western medicine. Comparative assessments were made between the two groups on pelvic ascites volume, maximum ovary diameter, dysmenorrhea incidence post-oocyte retrieval, and safety indicators.

Results

There were no statistically significant differences between the treatment group and the control group in terms of general characteristics or the levels of follicle-stimulating hormone (FSH), luteotropic hormone (LH), estradiol (E2), or progesterone (P) at the time of gonadotropin (Gn) initiation. The groups did not differ significantly when we compared the levels of LH, E2, or P on the day of human chorionic gonadotropin (hCG) injection and during ovarian hyperstimulation protocols (P > 0.05 for all indicators). The differences in the volume of pelvic ascites, the maximum ovarian diameter, and the incidence of dysmenorrhea after oocyte retrieval were statistically significant between the treatment group and the control group (P < 0.05 in both). There were no instances of adverse reactions in either group.

Conclusion

Based on the traditional Chinese medicine principle of "triple prevention", the use of Dan'e Fukang soft extracts for the simultaneous treatment of blood and fluid in moderate OHSS significantly improved the absorption of pelvic ascites, promoted ovarian recovery, and reduced the incidence of dysmenorrhea after oocyte retrieval.

Planned oocyte cryopreservation to preserve future reproductive potential: an Ethics Committee opinion

Planned oocyte cryopreservation is an ethically permissible procedure that may help individuals avoid future infertility. Because planned oocyte cryopreservation is new and evolving, it is essential that those considering using it be informed about the uncertainties regarding its efficacy and long-term effects. This replaces the document of the same name, last published in 2017.

Age at menarche and risk of ovarian hyperstimulation syndrome in women undergoing IVF/ICSI cycles: a retrospective cohort study

OBJECTIVES

We aimed to explore the association between age at menarche (AAM) and ovarian hyperstimulation syndrome (OHSS) in fresh in vitro fertilisation (IVF)/intracytoplasmic sperm injection (ICSI) cycles.

DESIGN

A retrospective cohort study.

SETTING

Data were collected from a large obstetrics and gynaecology hospital in Sichuan, China.

PARTICIPANTS

This study included 17 419 eligible women aged ≤40 years who underwent the first IVF/ICSI cycles from January 2015 to December 2021. Women were divided into three groups according to their AAM: ≤12 years (n=5781), 13-14 years (n=9469) and ≥15 years (n=2169).

RESULTS

The means of age at recruitment and AAM were 30.4 years and 13.1 years, respectively. Restricted cubic spline models suggested that early menarche age increased the risk of OHSS. The multivariable logistic analysis showed that women with menarche age ≤12 years were more likely to suffer from OHSS (OR 1.321, 95% CI 1.113 to 1.567) compared with those aged 13-14 years among the whole cohort. This significant relationship remained in women administered with different ovarian stimulation protocols and gonadotrophin doses. When stratified by female age, this correlation was presented only in patients aged ≤30 years (OR 1.362, 95% CI 1.094 to 1.694). And the mediation analysis showed that the relationship between AAM and OHSS was totally mediated by antral follicle counts (AFC).

CONCLUSION

Menarche age earlier than 12 years may increase the OHSS risk in women aged ≤30 years through the mediation of AFC. More prospective studies are required to verify the results.

Effect of GnRH agonist trigger with or without low-dose hCG on reproductive outcomes for PCOS women with freeze-all strategy: a propensity score matching study

PURPOSE

This study aimed to compare the effect of gonadotropin-releasing hormone agonist (GnRHa) trigger alone versus dual trigger comprising GnRHa and low-dose human chorionic gonadotropin (hCG) on reproductive outcomes in patients with polycystic ovary syndrome (PCOS) who received the freeze-all strategy.

METHODS

A total of 615 cycles were included in this retrospective cohort study. Propensity score matching (PSM) was performed to control potential confounding factors between GnRHa-trigger group (0.2 mg GnRHa) and dual-trigger group (0.2 mg GnRHa plus 1000/2000 IU hCG) in a 1:1 ratio. Multivariate logistic regression was applied to estimate the association between trigger methods and reproductive outcomes.

RESULTS

After PSM, patients with dual trigger (n = 176) had more oocytes retrieved, mature oocytes, and 2PN embryos compared to that with GnRHa trigger alone. However, the oocytes maturation rate, normal fertilization rate, and frozen embryos between the two groups were not statistically different. The incidence of ovarian hyperstimulation syndrome (OHSS) (14.8% vs. 2.8%, P < 0.001) and moderate/severe OHSS (11.4% vs. 1.7%, P < 0.001) were significantly higher in dual-trigger group than in GnRHa-alone group. Logistic regression analysis showed the adjusted odds ratio of dual trigger was 5.971 (95% confidence interval 2.201-16.198, P < 0.001) for OHSS. The pregnancy and single neonatal outcomes were comparable between the two groups (P > 0.05).

CONCLUSION

For PCOS women with freeze-all strategy, GnRHa trigger alone decreased the risk of OHSS without damaging oocyte maturation and achieved satisfactory pregnancy outcomes.

TGF-β1 and TGF-β3, but not TGF-β2, are upregulated in the ovaries of ovarian hyperstimulation syndrome†

Ovarian hyperstimulation syndrome (OHSS) is a life-threatening and potentially fatal complication during in vitro fertilization treatment. The levels of transforming growth factor-β1 (TGF-β1) are upregulated in human follicular fluid and granulosa-lutein cells (hGL) of OHSS patients and could contribute to the development of OHSS by downregulating steroidogenic acute regulatory protein (StAR) expression. However, whether the same is true for the other two members of the TGF-β family, TGF-β2 and -β3, remains unknown. We showed that all three TGF-β isoforms were expressed in human follicular fluid. In comparison, TGF-β1 was expressed at the highest level, followed by TGF-β2 and TGF-β3. Compared to non-OHSS patients, follicular fluid levels of TGF-β1 and TGF-β3 were significantly upregulated in OHSS patients. The same results were observed in mRNA levels of TGF-β isoforms in hGL cells and ovaries of OHSS rats. In addition, StAR mRNA levels were upregulated in hGL cells of OHSS patients and the ovaries of OHSS rats. Treatment cells with TGF-β isoforms downregulated the StAR expression with a comparable effect. Moreover, activations of SMAD3 signaling were required for TGF-β isoforms-induced downregulation of StAR expression. This study indicates that follicular fluid TGF-β1 and TGF-β3 levels could be used as biomarkers and therapeutic targets for the OHSS.

Individualised gonadotropin dose selection using markers of ovarian reserve for women undergoing in vitro fertilisation plus intracytoplasmic sperm injection (IVF/ICSI)

BACKGROUND

During a stimulated cycle of in vitro fertilisation or intracytoplasmic sperm injection (IVF/ICSI), women receive daily doses of gonadotropin follicle-stimulating hormone (FSH) to induce multifollicular development in the ovaries. A normal response to stimulation (e.g. retrieval of 5 to 15 oocytes) is considered desirable. Generally, the number of eggs retrieved is associated with the dose of FSH. Both hyper-response and poor response are associated with an increased chance of cycle cancellation. In hyper-response, this is due to increased risk of ovarian hyperstimulation syndrome (OHSS), while poor response cycles are cancelled because the quantity and quality of oocytes is expected to be low. Clinicians often individualise the FSH dose using patient characteristics predictive of ovarian response. Traditionally, this meant women's age, but increasingly, clinicians use various ovarian reserve tests (ORTs). These include basal FSH (bFSH), antral follicle count (AFC), and anti-Müllerian hormone (AMH). It is unclear whether individualising FSH dose improves clinical outcomes. This review updates the 2018 version.

OBJECTIVES

To assess the effects of individualised gonadotropin dose selection using markers of ovarian reserve in women undergoing IVF/ICSI.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group Specialised Register of controlled trials, CENTRAL, MEDLINE, Embase, and two trial registers in February 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared (a) different doses of FSH in women with a defined ORT profile (i.e. predicted low, normal, or high responders based on AMH, AFC, and/or bFSH) or (b) an individualised dosing strategy (based on at least one ORT measure) versus uniform dosing or a different individualised dosing algorithm.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Primary outcomes were live birth/ongoing pregnancy and severe OHSS.

MAIN RESULTS

We included 26 studies, involving 8520 women (6 new studies added to 20 studies included in the previous version). We treated RCTs with multiple comparisons as separate trials for the purpose of this review. Meta-analysis was limited due to clinical heterogeneity. Evidence certainty ranged from very low to low, with the main limitations being imprecision and risk of bias associated with lack of blinding. Direct dose comparisons according to predicted response in women Due to differences in dose comparisons, caution is required when interpreting the RCTs in predicted low responders. All evidence was low or very low certainty. Effect estimates were very imprecise, and increased FSH dosing may or may not have an impact on rates of live birth/ongoing pregnancy, OHSS, and clinical pregnancy. Similarly, in predicted normal responders (10 studies, 4 comparisons), higher doses may or may not impact the probability of live birth/ongoing pregnancy (e.g. 200 versus 100 international units (IU): odds ratio (OR) 0.88, 95% confidence interval (CI) 0.57 to 1.36; I2 = 0%; 2 studies, 522 women) or clinical pregnancy. Results were imprecise, and a small benefit or harm remains possible. There were too few events for the OHSS outcome to enable inferences. In predicted high responders, lower doses may or may not affect live birth/ongoing pregnancy (OR 0.98, 95% CI 0.66 to 1.46; 1 study, 521 women), severe OHSS, and clinical pregnancy. It is also unclear whether lower doses reduce moderate or severe OHSS (Peto OR 2.31, 95% CI 0.80 to 6.67; 1 study, 521 participants). ORT-algorithm studies Eight trials compared an ORT-based algorithm to a non-ORT control group. It is unclear whether live birth/ongoing pregnancy and clinical pregnancy are increased using an ORT-based algorithm (live birth/ongoing pregnancy: OR 1.12, 95% CI 0.98 to 1.29; I2 = 30%; 7 studies, 4400 women; clinical pregnancy: OR 1.04, 95% CI 0.91 to 1.18; I2 = 18%; 7 studies, 4400 women; low-certainty evidence). However, ORT algorithms may reduce moderate or severe OHSS (Peto OR 0.60, 95% CI 0.42 to 0.84; I2 = 0%; 7 studies, 4400 women; low-certainty evidence). There was insufficient evidence to determine whether the groups differed in rates of severe OHSS (Peto OR 0.74, 95% CI 0.42 to 1.28; I2 = 0%; 5 studies, 2724 women; low-certainty evidence). Our findings suggest that if the chance of live birth with a standard starting dose is 25%, the chance with ORT-based dosing would be between 25% and 31%. If the chance of moderate or severe OHSS with a standard starting dose is 5%, the chance with ORT-based dosing would be between 2% and 5%. These results should be treated cautiously due to heterogeneity in the algorithms: some algorithms appear to be more effective than others.

AUTHORS' CONCLUSIONS

We did not find that tailoring the FSH dose in any particular ORT population (low, normal, high ORT) affected live birth/ongoing pregnancy rates, but we could not rule out differences, due to sample size limitations. Low-certainty evidence suggests that it is unclear if ORT-based individualisation leads to an increase in live birth/ongoing pregnancy rates compared to a policy of giving all women 150 IU. The confidence interval is consistent with an increase of up to around six percentage points with ORT-based dosing (e.g. from 25% to 31%) or a very small decrease (< 1%). A difference of this magnitude could be important to many women. It is unclear if this is driven by improved outcomes in a particular subgroup. Further, ORT algorithms reduced the incidence of OHSS compared to standard dosing of 150 IU. However, the size of the effect is also unclear. The included studies were heterogeneous in design, which limited the interpretation of pooled estimates. It is likely that different ORT algorithms differ in their effectiveness. Current evidence does not provide a clear justification for adjusting the dose of 150 IU in poor or normal responders, especially as increased dose is associated with greater total FSH dose and cost. It is unclear whether a decreased dose in predicted high responders reduces OHSS, although this would appear to be the most likely explanation for the results.

Reinfusion of peritoneal fluid elevates the level of plasma D-dimer in patients with early-onset ovarian hyperstimulation syndrome

Purpose

This study aimed to elucidate the factors that affect the dynamics of blood D-dimer in ovarian hyperstimulation syndrome (OHSS).

Methods

We retrospectively reviewed medical records from two hospitals and extracted data obtained during assisted reproductive technology and OHSS treatment. Blood D-dimer levels during hospitalization were plotted against body weight. Other factors possibly related to blood D-dimer levels were also analyzed.

Results

The analysis included 10 patients with OHSS admitted between January 2013 and June 2023. In all patients, blood D-dimer levels increased significantly when they convalesced from OHSS and lost weight. None of the patients showed clinical signs of thrombosis, which was confirmed using imaging tests in 8 of 10 patients. Two patients underwent cell-free and concentrated ascites reinfusion therapy (CART), and their blood D-dimer levels increased dramatically after the procedure.

Conclusion

Weight change and CART are associated with blood D-dimer dynamics in OHSS. Our results show that elevated blood D-dimer levels in patients with OHSS do not always represent the presence of thrombosis. Reinfusion of pooled D-dimer in ascites may explain the D-dimer surge during the recovery phase or after CART in these patients. Our study provides new perspectives on the clinical implications of D-dimer during OHSS.

Planned Oocyte Cryopreservation: A Review of Current Evidence on Outcomes, Safety and Risks

Although oocyte cryopreservation was initially used as a fertility preservation strategy for medical indications, it is now is increasingly used to circumvent age-related infertility. Outcomes following planned oocyte vitrification, also known as elective egg freezing, are limited. Current studies show higher success rates for individuals undergoing fertility preservation treatment under age 35. Additionally, while freezing 20 oocytes is optimal to achieve pregnancy, freezing at least 8-10 oocytes is recommended. While fertility is not guaranteed, current evidence demonstrates that planned oocyte vitrification is an overall safe, low risk method of fertility preservation to reduce the risk for age-related infertility.

Does cabergoline administration affect endometrial VEGFR-2 expression in a rat model of ovarian hyperstimulation syndrome?

OBJECTIVE

To assess the effect of cabergoline on endometrial vascular endothelial growth factor receptor-2 (VEGFR-2) immunoexpression in an ovarian hyperstimulation syndrome (OHSS) rat model.

MATERIAL AND METHODS

Twenty-one immature female Wistar rats were assigned into three groups: group 1, the control group; group 2, stimulated with gonadotropins to mimic OHSS; and group 3, in which an OHSS protocol was induced and thereafter treated with cabergoline (100 μg/kg/day). Body weight, ovarian volume, corpora lutea numbers, and endometrial VEGFR-2 expression were compared between the groups.

RESULTS

Weight gain and ovarian volume were highest in the OHSS-placebo group, while cabergoline administration significantly reversed those effects (p = 0.001 and p = 0.001, respectively). VEGFR-2 stained cells were significantly lower in groups 2 and 3 compared to group 1 (p = 0.002). Although VEGFR-2 expression was lowest in group 3, the difference was not statistically significant. Corpora lutea numbers were also similar (p = 0.465).

CONCLUSION

While successful implantation requires a vascularized receptive endometrium, impaired expression of VEGFR-2 and disrupted endometrial angiogenesis due to cabergoline administration may be associated with IVF failure in fresh OHSS cycles. The insignificant decrease in endometrial VEGFR-2 expression observed in this research needs to be investigated by further studies involving additional techniques such as immunoblotting and/or RT-PCR analyses.

Incidence and severity of ovarian hyperstimulation syndrome (OHSS) in high responders after gonadotropin-releasing hormone (GnRH) agonist trigger in "freeze-all" approach

OBJECTIVE

To determine the incidence and severity of ovarian hyperstimulation syndrome (OHSS) in high responders (25-35 follicles with a diameter of ≥12 mm on day of triggering) who received a gonadotropin-releasing hormone (GnRH) agonist to trigger final follicular maturation.

METHODS

We used individual data from women who participated in four different clinical trials and were high responders to ovarian stimulation in a GnRH antagonist protocol in this retrospective combined analysis. All women were evaluated for signs and symptoms of OHSS using identical criteria based on Golan's system (1989).

RESULTS

High responders (n = 77) were of different ethnicities. There were no differences in baseline characteristics between women with or without signs and symptoms of OHSS. Mean ± standard deviation baseline data were: age, 32.3 ± 3.5 years; anti-Müllerian hormone, 42.4 ± 20.7 pmol/L; antral follicle count, 21.5 ± 9.2. Before triggering, duration of stimulation was 9.5 ± 1.6 days and the mean number of follicles with a diameter of ≥12 mm and ≥17 mm was 26.5 ± 4.4 and 8.8 ± 4.7, respectively. Mean serum estradiol (17,159 pmol/l) and progesterone (5.1 nmol/l) levels were high at 36 h after triggering. Overall, 17/77 high responders (22%) developed signs and symptoms of mild OHSS which lasted 6-21 days. The most frequently prescribed medication was cabergoline to prevent worsening of OHSS. No severe OHSS occurred and no OHSS cases were reported as serious adverse events.

CONCLUSIONS

High responders receiving GnRH agonist for triggering should be informed that they may experience signs and symptoms of mild OHSS.

Comparison of Three Ovulation Induction Therapies for Patients With Polycystic Ovary Syndrome and Infertility

The purpose of this research was to evaluate the efficacy of 3 ovulation induction therapies for treating infertility in patients with polycystic ovary syndrome (PCOS). In this retrospective study, we compared the success rates of 90 patients who underwent intrauterine insemination, who were randomly assigned to 1 of 3 treatment groups: letrozole (LE) + urinary gonadotropin (human menopausal gonadotropin [HMG]), clomiphene (CC) + HMG, or HMG alone. Using ultrasound scanning, we examined the number of mature follicles, ovulation rate, clinical pregnancy rate, endometrial thickness, and blood flow. When compared to the other 2 groups, the LE + HMG group had significantly higher levels of mature follicles, ovulation rate, clinical pregnancy rate, estradiol, and luteinizing hormone on the day of the human chorionic gonadotropin injection and endometrial receptivity (P < .05). There was no statistically significant difference between the 3 groups in terms of abortion rate, ectopic pregnancy rate, or adverse reactions. In this research, we found that infertility in patients with PCOS could be effectively treated by combining LE with HMG. This protocol increased ovulation, boosted fertility, and enhanced endometrial receptivity with no increase in adverse reactions. Therefore, it may be a useful clinical approach for inducing ovulation and treating infertility in patients with PCOS.

Real-world practices of hormone monitoring during ovarian stimulation in assisted reproductive technology: a global online survey

Objective

The aim of this study is to understand the global practice of routine hormonal monitoring (HM) during ovarian stimulation (OS) in the context of assisted reproductive technique (ART) treatment.

Methods

An open-access questionnaire was available to 3,845 members of IVF-Worldwide.com from September 8 to October 13, 2021. The survey comprised 25 multiple-choice questions on when and how ultrasound (US) and hormone tests were conducted during ovarian stimulation OS. For most questions, respondents were required to select a single option. Some questions allowed the selection of multiple options.

Results

In all, 528 (13.7%) members from 88 countries responded to the questionnaire. Most respondents (98.9%) reported using US to monitor OS cycles. HM was used by 79.5% of respondents during any of the cycle monitoring visits and was most commonly performed on the day of, or a day prior to final oocyte maturation. Overall, 87% of respondents claimed adjusting the dose of gonadotropin during OS, with 61.7% adjusting the dose based on hormonal levels. Oestradiol (E2) was the most frequently monitored hormone during all visits and was used by 74% of respondents for the prediction of ovarian hyperstimulation syndrome (OHSS). On or a day prior to ovulation triggering (OT), the number of respondents who measured progesterone increased from 34.3% in the second/third visit to 67.7%. Approximately one-third of respondents measured luteinizing hormone during all visits.

Conclusion

Globally, most ART specialists (~80%) use HM, along with US, for monitoring OS, especially for the prevention of OHSS.

A prediction model for high ovarian response in the GnRH antagonist protocol

Backgrounds

The present study was designed to establish and validate a prediction model for high ovarian response (HOR) in the GnRH antagonist protocol.

Methods

In this retrospective study, the data of 4160 cycles were analyzed following the in vitro fertilization (IVF) at our reproductive medical center from June 2018 to May 2022. The cycles were divided into a training cohort (n=3121) and a validation cohort (n=1039) using a random sampling method. Univariate and multivariate logistic regression analyses were used to screen out the risk factors for HOR, and the nomogram was established based on the regression coefficient of the relevant variables. The area under the receiver operating characteristic curve (AUC), the calibration curve, and the decision curve analysis were used to evaluate the performance of the prediction model.

Results

Multivariate logistic regression analysis revealed that age, body mass index (BMI), follicle-stimulating hormone (FSH), antral follicle count (AFC), and anti-mullerian hormone (AMH) were independent risk factors for HOR (all P< 0.05). The prediction model for HOR was constructed based on these factors. The AUC of the training cohort was 0.884 (95% CI: 0.869-0.899), and the AUC of the validation cohort was 0.884 (95% CI:0.863-0.905).

Conclusion

The prediction model can predict the probability of high ovarian response prior to IVF treatment, enabling clinicians to better predict the risk of HOR and guide treatment strategies.

The HERA (Hyper-response Risk Assessment) Delphi consensus for the management of hyper-responders in in vitro fertilization

PURPOSE

To provide agreed-upon guidelines on the management of a hyper-responsive patient undergoing ovarian stimulation (OS) METHODS: A literature search was performed regarding the management of hyper-response to OS for assisted reproductive technology. A scientific committee consisting of 4 experts discussed, amended, and selected the final statements. A priori, it was decided that consensus would be reached when ≥66% of the participants agreed, and ≤3 rounds would be used to obtain this consensus. A total of 28/31 experts responded (selected for global coverage), anonymous to each other.

RESULTS

A total of 26/28 statements reached consensus. The most relevant are summarized here. The target number of oocytes to be collected in a stimulation cycle for IVF in an anticipated hyper-responder is 15-19 (89.3% consensus). For a potential hyper-responder, it is preferable to achieve a hyper-response and freeze all than aim for a fresh transfer (71.4% consensus). GnRH agonists should be avoided for pituitary suppression in anticipated hyper-responders performing IVF (96.4% consensus). The preferred starting dose in the first IVF stimulation cycle of an anticipated hyper-responder of average weight is 150 IU/day (82.1% consensus). ICoasting in order to decrease the risk of OHSS should not be used (89.7% consensus). Metformin should be added before/during ovarian stimulation to anticipated hyper-responders only if the patient has PCOS and is insulin resistant (82.1% consensus). In the case of a hyper-response, a dopaminergic agent should be used only if hCG will be used as a trigger (including dual/double trigger) with or without a fresh transfer (67.9% consensus). After using a GnRH agonist trigger due to a perceived risk of OHSS, luteal phase rescue with hCG and an attempt of a fresh transfer is discouraged regardless of the number of oocytes collected (72.4% consensus). The choice of the FET protocol is not influenced by the fact that the patient is a hyper-responder (82.8% consensus). In the cases of freeze all due to OHSS risk, a FET cycle can be performed in the immediate first menstrual cycle (92.9% consensus).

CONCLUSION

These guidelines for the management of hyper-response can be useful for tailoring patient care and for harmonizing future research.

Melatonin Ameliorates Ovarian Hyperstimulation Syndrome (OHSS) through SESN2 Regulated Antiapoptosis

Background

Ovarian hyperstimulation syndrome (OHSS) is one of the most severe complications after ovarian stimulation during assisted reproductive technology (ART). However, its pathogenesis still remains unclear. Melatonin is an important antioxidant factor in female reproduction and Sestrin-2 (SESN2) is reported to be involved in cellular response to different stress conditions. Whether or not melatonin and SESN2 are involved in OHSS is still a question to us clinicians.

Methods and Results

We collected the granulosa cells of OHSS patients and focused on the role of SESN2 in OHSS. We also studied the role and mechanism of melatonin plays in OHSS patients. We found that the expression of SESN2 was increased in the granulosa cells of OHSS patients (n = 24) than those in controls (n = 15). Incubation with angiotensin II (1 μM, 2 μM) in HUVECs and H2O2 (0.1 mM, 0.2 mM) in KGNs increased the generation of ROS concurrent with the increased expression of SESN2, while melatonin treatment partly restored SESN2 levels. The mechanism study demonstrated that SESN2 was deeply involved in the regulation of AMPK and mTOR, whereas melatonin partially restored angiotensin II or H2O2 induced the activation of AMPK phosphorylation and the inhibition of mTOR, 4EBP1 and S6K1 phosphorylation, all of which could trigger cell apoptosis.

Conclusions

These findings indicated that melatonin attenuated ROS-induced apoptosis through SESN2-AMPK-mTOR in OHSS. Thus, melatonin is likely to be a potential and important therapeutic agent for treating and preventing OHSS.

Association between serum AMH levels and IVF/ICSI outcomes in patients with polycystic ovary syndrome: a systematic review and meta-analysis

CONTEXT

Anti-Müllerian hormone (AMH) levels are increased in polycystic ovary syndrome (PCOS) patients and are associated with PCOS severity.

OBJECTIVE

To evaluate the associations between serum AMH levels and in vitro fertilization (IVF)/ intracytoplasmic sperm injection (ICSI) outcomes in patients with PCOS.

DATA SOURCES

PubMed, Embase, and the Cochrane Library were searched on 11 July 2022.

STUDY SELECTION

Studies reporting the association between serum AMH levels and IVF/ICSI outcomes in PCOS patients were considered for inclusion. The primary outcomes were clinical pregnancy, live birth, and ovarian hyperstimulation syndrome.

DATA EXTRACTION

Data were extracted using a standardized data extraction form. Study quality was assessed independently by two groups of researchers.

DATA SYNTHESIS

Nineteen studies were included in this review. Meta-analyses demonstrated that PCOS patients with a serum AMH level within the 75-100th percentile had a decreased odds of clinical pregnancy (OR: 0.77, 95% CI: 0.63-0.93) and livebirth (OR: 0.71; 95% CI: 0.58-0.87) compared to those within the 0-25th percentile. An increased AMH level was also correlated with an increased number of oocytes retrieved (SMD: 0.90, 95% CI: 0.30-1.51) and a lower odds of fertilization (OR: 0.92, 95% CI: 0.87-0.98). There was no significant difference in the number of MII oocytes (SMD: 1.85, 95% CI: -1.07-4.78), E2 on the day of hCG (SMD: 0.12; 95% CI: -0.98-1.23), or implantation (OR: 0.82, 95% CI: 0.28-2.39) between the two groups. In addition, we found significant dose-response associations between serum AMH level and clinical pregnancy, live birth, number of oocytes retrieved, and fertilization in PCOS patients.

CONCLUSION

AMH may have clinical utility in counseling regarding IVF/ICSI outcomes among women with PCOS who wish to undergo fertility treatment. More large-scale, high-quality cohort studies are needed to confirm these findings.

Clinical characteristics of functioning gonadotroph adenoma in women presenting with ovarian hyperstimulation: Audit of UK pituitary centres

OBJECTIVE

Functioning gonadotroph adenomas (FGAs) are rare pituitary tumours stimulating ovarian function with potential life-threatening consequences in women. However, a lack of aggregated clinical experience of FGAs impairs management in affected women. The aim of this study is to present the clinical course of FGA-induced ovarian hyperstimulation syndrome (OHSS) cases as identified by some of the largest UK pituitary endocrine tertiary centres with a view to increasing awareness and improving diagnosis and management of women with FGA.

DESIGN

A retrospective observational study; audit of eight UK regional pituitary centres for cases of FGAs.

SETTING

Specialist neuroendocrine centres in the United Kingdom.

PATIENTS AND MEASUREMENTS

Women diagnosed with FGA-induced OHSS. Description of their clinical course.

RESULTS

Seven cases of FGA were identified in women, all causing OHSS. Mean age was 33.4 years at diagnosis. Abdominal pain, irregular periods, headache, and visual disturbances were reported at presentation by 100%, 71%, 57% and 43% of women, respectively. Three of seven women underwent ovarian surgery before FGA diagnosis. Six women underwent transsphenoidal surgery (TSS) with incomplete tumour resection in five of those, but all showed improvement or resolution in symptoms and biochemistry postoperatively.

CONCLUSION

FGA is a rare cause of spontaneous OHSS. TSS improves clinical and biochemical features of ovarian hyperstimulation in FGAs. Improved awareness of FGA will prevent inappropriate emergency ovarian surgery.