Should we still advise infertile couples to use (barrier) contraception before IVF down-regulation?

Exposure to gonadotropin-releasing hormone agonist in early pregnancy leads to adverse pregnancy outcomes: a retrospective analysis

BACKGROUND

GnRH-a is commonly used in the luteal phase for pituitary down-regulation during in-vitro fertilization (IVF). There is an ineluctable risk of spontaneous pregnancy for infertile couples who lack the use of contraception during the luteal phase down-regulation before IVF treatment. However, it is unclear whether exposure to GnRH-a affects clinical pregnancy outcomes.

METHODS

A single-center retrospective cohort study based on propensity score matching was used to analyze the clinical data of a total of 6602 infertile women who were about to undergo assisted reproduction with IVF or intracytoplasmic microsperm injection with spermatozoa (ICSI) and with confirmed clinical pregnancies outcomes in the Reproductive Center of Sun Yat-sen Memorial Hospital, Sun Yat-sen University, China, from January 2011 to December 2022. Participants were divided into the NP group (Natural pregnancy with the use of GnRH-a) and the CT group (Conceived through IVF/ICSI-ET). Baseline characteristics and pregnancy outcomes of the groups were compared by correlation analysis, analysis of variance, and generalized estimating equations. The correlation between pregnancy outcomes and GnRH-a exposure was analyzed based on logistic regression modeling. The primary outcome of the study is the ectopic pregnancy rate. The secondary outcomes included spontaneous abortion rate, clinical pregnancy rate, live birth rate and adverse neonatal outcomes rate.

RESULTS

Our study demonstrates statistically significant differences in spontaneous abortion rate (29.5% vs. 13.6%, P < 0.05), ectopic pregnancy rate (14.3% vs. 3.1%, P < 0.05), live birth rate ((56.2% vs. 83.3%, P < 0.05)) between NP group and CT group. Logistic analysis showed that exposure to GnRH-a was a risk factor for adverse pregnancy outcomes and was associated with spontaneous abortion(odds ratio[ OR], 95% confidence interval [95% CI] {2.66,1.61-4.40}, P < 0.05) and ectopic pregnancy(odds ratio [OR], 95%confidence interval [95% CI] {5.21,2.39-11.32}, P < 0.05).

CONCLUSION

Exposure to GnRH-a during the luteal phase of down-regulation can adversely affect pregnancy outcomes. Therefore, we recommend contraception during the IVF/ICSI down-regulation. A higher dose of progesterone during early pregnancy is needed for infertile women who conceive spontaneously after exposure to GnRH-a.

No significant long-term complications from inadvertent exposure to gonadotropin-releasing hormone agonist during early pregnancy in mothers and offspring: a retrospective analysis

BACKGROUND

Administration of gonadotropin-releasing hormone agonist (GnRH-a) in the luteal phase is commonly used for pituitary suppression during in vitro fertilisation (IVF). There is an ineluctable risk of inadvertent exposure of spontaneous pregnancy to GnRH-a. However, little is known about the pregnancy complications and repregnancy outcomes of the affected women and the neurodevelopmental outcomes of the GnRH-a-exposed children.

METHODS

Retrospective analysis was used to determine obstetric and repregnancy outcomes after natural conception in 114 women who naturally conceived while receiving GnRH-a during their early pregnancy over the past 17 years. The GnRH-a-exposed children were evaluated to determine their neonatal characteristics and long-term neurodevelopmental outcomes. The outcomes were compared to those of relevant age-matched control groups.

RESULTS

Sixty-five women had 66 live births. The neonatal health outcomes and the incidence of maternal complications were similar in the GnRH-a-exposed and control groups. Thirty-one GnRH-a-exposed children, aged 2-8 years, were available for investigation of neurodevelopment. Except for one case of autism spectrum disorder, the full-scale intelligence quotient score was within the normal range and similar to that of the control group. Most mothers with successful pregnancies and about one-third of the women who had spontaneous abortions were subsequently able to conceive naturally again. IVF is recommended for repregnancy in women who have experienced ectopic pregnancies.

CONCLUSIONS

Accidental exposure to GnRH-a in early pregnancy might be safe. Reproductive treatment suggestions for repregnancy should be made with consideration of the outcomes of the previously GnRH-a-exposed spontaneous pregnancy.

EUROmediCAT signal detection: an evaluation of selected congenital anomaly-medication associations

AIMS

To evaluate congenital anomaly (CA)-medication exposure associations produced by the new EUROmediCAT signal detection system and determine which require further investigation.

METHODS

Data from 15 EUROCAT registries (1995-2011) with medication exposures at the chemical substance (5th level of Anatomic Therapeutic Chemical classification) and chemical subgroup (4th level) were analysed using a 50% false detection rate. After excluding antiepileptics, antidiabetics, antiasthmatics and SSRIs/psycholeptics already under investigation, 27 associations were evaluated. If evidence for a signal persisted after data validation, a literature review was conducted for prior evidence of human teratogenicity.

RESULTS

Thirteen out of 27 CA-medication exposure signals, based on 389 exposed cases, passed data validation. There was some prior evidence in the literature to support six signals (gastroschisis and levonorgestrel/ethinylestradiol (OR 4.10, 95% CI 1.70-8.53; congenital heart disease/pulmonary valve stenosis and nucleoside/tide reverse transcriptase inhibitors (OR 5.01, 95% CI 1.99-14.20/OR 28.20, 95% CI 4.63-122.24); complete absence of a limb and pregnen (4) derivatives (OR 6.60, 95% CI 1.70-22.93); hypospadias and pregnadien derivatives (OR 1.40, 95% CI 1.10-1.76); hypospadias and synthetic ovulation stimulants (OR 1.89, 95% CI 1.28-2.70). Antipropulsives produced a signal for syndactyly while the literature revealed a signal for hypospadias. There was no prior evidence to support the remaining six signals involving the ordinary salt combinations, propulsives, bulk-forming laxatives, hydrazinophthalazine derivatives, gonadotropin releasing hormone analogues and selective serotonin agonists.

CONCLUSION

Signals which strengthened prior evidence should be prioritized for further investigation, and independent evidence sought to confirm the remaining signals. Some chance associations are expected and confounding by indication is possible.

Effect of duration of the GnRH agonists in the luteal phase in the outcome of assisted reproduction cycles

The effect of long-acting GnRHa, in the luteal phase, during ART cycles varies from one patient to another. The aim of this study was to evaluate whether the effect of long-acting GnRHa in the luteal phase, in ART cycles, affects pregnancy rates according to the duration of its action in such phase. This is a retrospective study of 367 patients submitted to ovulation induction for in vitro fertilization/intracytoplasmic sperm injection procedures that used long-acting depot GnRHa for pituitary suppression. Patients were stratified according to the period of action of the agonist in the luteal phase: group 1, ≤ 6 days; group 2, 7 to 12 days; and group 3, >12 days. The following variables were analyzed: ovarian response, age, infertility causes and pregnancy rates. Group 1 (n = 53) had a mean age of 33.8 ± 4.55 years (23-44 years) and a pregnancy rate of 45.2%. In group 2 (n = 118), mean age was 33.7 ± 4.5 years (24-44 years) and the pregnancy rate was 38.9%. In group 3 (n = 196), mean age was 33.7 ± 4.4 years (23-43 years) and the pregnancy rate was 47.4%. Regardless of the duration of depot GnRHa action in the luteal phase, no significant association with pregnancy rates was found.

Efficacy and safety of long-acting GnRH agonists in in vitro fertilization and embryo transfer

The introduction of gonadotrophin-releasing hormone (GnRH) agonists combined with gonadotrophins is considered to be one of the most significant events in the development of in vitro fertilization and embryo transfer (IVF-ET) programmes. This article reviews the use of GnRH agonists in IVF-ET programmes and the efficacy and safety of long-acting GnRH agonists. The use of agonists results in higher clinical pregnancy rates, more supernumerary embryos for cryopreservation and allows convenient programming of oocyte recovery. There are different types of agonist and ovarian stimulation protocol available for clinical use. Recent meta-analysis of the Cochrane database has demonstrated the superiority of the long protocols over the short and ultra-short protocols for GnRH agonist use in IVF and GIFT. The depot injection offers increased clinical and patient compliance and improves efficacy of pituitary downregulation. However, compared with short-acting agonists, the depot preparations are associated with a longer period of stimulation and higher doses of gonadotrophins. To date, there is no evidence of an increased risk of pregnancy wastages or teratogenicity in human pregnancies exposed to long-acting agonists.

Perinatal outcome of pregnancies after inadvertent exposure to gonadotrophin-releasing hormone analogue

BACKGROUND

The use of gonadotrophin-releasing hormone agonists (GnRHa) in in vitro fertilisation (IVF) cycles is accepted as standard practice. However, the safety profile of this drug with inadvertent exposure in pregnancy is still in question.

AIM

To evaluate the pregnancy outcomes in a group of infertile patients who conceive spontaneously while undergoing IVF with unrecognised daily exposure to GnRHa during the downregulation regime.

METHODS

A review of all women undergoing planned treatment cycles in our IVF centre, comprising of a total of 1949 fresh and 154 frozen embryo cycles from January 1996 to December 2001. All spontaneous pregnancies were recorded and case records reviewed.

OUTCOME MEASURE

Course and clinical outcome of pregnancies.

RESULTS

Nine spontaneous pregnancies were recorded (0.43%). The median duration of inadvertent exposure to subcutaneous leuprolide acetate was 22 days (range 21-25). The median age of the patients was 35 years (range 28-39) and the median duration of infertility was 3.5 years (range 1.5-8). Nine pregnancies resulted in miscarriages. Seven pregnancies progressed to term and resulted in singleton live births with no apparent evidence of fetal abnormalities or aneuploidies. One pregnancy was complicated by parvovirus infection at 19 weeks gestation with transient fetal hydrops. The pregnancy outcomes appear favourable even when compared to those conceived through the completed IVF cycles within the same cohort.

CONCLUSION

Our experience reaffirms current evidence from earlier studies that accidental exposure to GnRHa in early pregnancy is safe. However, we believe that contraception prior to GnRHa is still prudent pending definitive data.

Safety of drugs used in assisted reproduction techniques

Infertility may affect one in six couples; however, the development of the assisted reproduction technique (ART) created the opportunity for a large proportion of the infertile population to bear children. Pharmacological agents are routinely used in ART, and new ones are introduced regularly, with the aim of retrieving multiple oocytes to increase the prospect of pregnancy. The combinations of drugs that are used have specific adverse effects, but it is mostly the combined action of more than one agent that causes the greatest concern. The matter is complicated by the suspicion that some techniques in ART, for example intracytoplasmic sperm injection for severe male infertility problems (including azoospermia), may also contribute to the increase in adverse effects, especially congenital malformation. Gonadotropin releasing hormone (GnRH) agonists are widely used in controlled ovarian hyperstimulation. It may give rise to a short period of estradiol withdrawal symptoms and it may also lead to luteal phase deficiency. Similarly GnRHa antagonists, which have been recently introduced to control ovarian hyperstimulation, can lead to luteal phase deficiency and may cause some local injection site reactions. The more pure form of gonadotropin leads to less local injection site reactions and their main adverse effects are associated with the consequences of multiple ovulations. It has been proposed that gonadotropins may be a factor in the increasing risk of ovarian cancer and possibly breast cancer, but this has not been substantiated. Prion infection is another potential hazard, although no cases have been reported. Ovarian hyperstimulation syndrome is a well recognised complication of controlled ovarian hyperstimulation in ART. It is usually a result of recruitment of a large number of ovarian follicles. Efforts to minimise the incidence of this syndrome and its severity are now well developed. Congenital malformations are another possible adverse effect of fertility drugs, but it is more probable that the increase in congenital abnormality that is reported in ART is because of the population studied, i.e. patients already at high risk of congenital malformation, rather than the fertility drugs used or the technique employed. High order multiple pregnancy and its sequela is a well established complication of controlled ovarian hyperstimulation. This could be a result of multiple ovulations or more than one embryo replacement. Reducing the number of embryos transferred can reduce this more serious adverse effect for expectant mothers and for children conceived from ART.

Achievement of pregnancy three times in the same patient during luteal GnRH agonist administration

Gonadotrophin-releasing hormone agonist (GnRHa) administration from the mid-luteal phase onwards is considered the gold standard of ovarian stimulation for IVF treatment. It might, however, coincide with an implanting spontaneous pregnancy. Concerns have therefore been raised with regard to the evolution of the resulting pregnancies and long-term outcome of the children born. The current case report describes the achievement of three pregnancies in the same patient during luteal administration of GnRHa. One pregnancy ended in spontaneous abortion and the other two resulted in the delivery of two female infants. The children have so far been followed for 3.5 and 7 years. The physical examination of both children was unremarkable. However, the older child has recently been diagnosed with attention deficit hyperactivity disorder and dyslexia.