The relative success of gonadotropin-releasing hormone analogue, clomiphene citrate, and gonadotropin in 1,099 cycles of in vitro fertilization

Comparison of pregnancy rates for poor responders using IVF with mild ovarian stimulation versus conventional IVF: a guideline

Mild-stimulation protocols with in vitro fertilization (IVF) generally aim to use less medication than conventional IVF. This guideline evaluates pregnancy and live-birth rates in patients expected to be poor responders using mild ovarian stimulation and natural-cycle protocols vs conventional IVF.

Sperm DNA fragmentation index does not correlate with blastocyst euploidy rate in egg donor cycles

Sperm DNA fragmentation is a known etiology for male infertility. We evaluated the impact of sperm DNA fragmentation index (DFI) on blastocyst euploidy in IVF cycles with egg donors. This observational retrospective study, which was conducted in a university affiliated fertility clinic, included IVF-ICSI-pre-implantation Genetic Screening (PGS) egg donor cycles in which DFI was tested prior to IVF, between January 1st, 2014 and July 31st, 2016. Twenty-seven cycles with DFI > 15% were included in the study group and compared with 18 cycles of DFI < 15% within control group. Research group participants had significantly lower sperm count and motility (55.4*10⁶/ml and 37.4%, respectively) compared with controls (92.5*10⁶/ml and 55.7%, respectively, p < .05). The groups were similar in terms of donors' demography (age, BMI), ovarian reserve (AMH, AFC) and response to hormonal stimulation (E2 level on triggering day and number of retrieved eggs). Embryo development (from 2PN through day 3 embryos to blastocysts) was similar as well. The number of biopsied blastocysts from study and control groups was 171 and 87, respectively. PGS with array comprehensive genomic hybridization revealed comparable euploidy rates of 69.3% and 67.3%, respectively (p > .05). DFI did not have an impact on the blastocyst euploidy rate in IVF cycles with egg donors.

Sperm DNA fragmentation index does not correlate with blastocyst aneuploidy or morphological grading

High DNA fragmentation index (DFI) may be associated with poor outcome after IVF. Our aim was to determine whether DFI impacts blastocyst quality or clinical outcome. This retrospective study included 134 couples who underwent 177 IVF-ICSI and pre-implantation genetic screening (PGS) cycles during January 1st, 2014-March 31st, 2016 and had documented previous DFI. Group 1 (DFI>30%) encompassed 25 couples who underwent 36 cycles; Group 2 (DFI 15-30%) included 45 couples and 57 cycles; group 3 (DFI<15%) included 64 couples and 83 cycles. Male partners within group 1 were older (45.1 compared to 40.6 and 38.3 years, respectively, p<0.05), had higher BMI (32.4 compared to 26.6 and 25.8 respectively, p<0.05) and lower sperm count and motility (46*106/ml and 35.5%, respectively) compared to groups 2 (61.8*106/ml and 46.6%, respectively) and 3 (75.8*106/ml and 55.1%, respectively, p<0.05). Female parameters including ovarian reserve and response and embryo development were similar. Total numbers of biopsied blastocysts were 116, 175 and 259 in groups 1, 2 and 3, respectively. PGS for 24 chromosomes revealed comparable euploidy rate of 46-50.4%, with a similar morphological classification. No significant differences were found regarding pregnancy rates or pregnancy loss. It seems that DFI doesn't correlate with blastocyst aneuploidy or morphological grading.

The use of coenzyme Q10 and DHEA during IUI and IVF cycles in patients with decreased ovarian reserve

OBJECTIVE

The objective of this study is to compare the combination of dehydroepiandrosterone (DHEA) and coenzyme Q10 (CoQ10) (D + C) with DHEA alone (D) in intrauterine insemination (IUI) and in vitro fertilization (IVF) cycles among patients with decreased ovarian reserve.

METHODS

We retrospectively extracted data from patients charts treated by DHEA with/without CoQ10 during IUI or IVF between February 2006 and June 2014. Prestimulation parameters included age, BMI, day 3 FSH and antral follicular count (AFC). Ovarian response parameters included total gonadotropins dosage, peak serum estradiol, number of follicles > 16 mm and fertilization rate. Clinical outcomes included clinical and ongoing pregnancy rates.

RESULTS

Three hundred and thirty IUI cycles involved D + C compared with 467 cycles of D; 78 IVF cycles involved D + C and 175 D. In both IUI and IVF, AFC was higher with D + C compared with D (7.4 ± 5.7 versus 5.9 ± 4.7, 8.2 ± 6.3 versus 5.2 ± 5, respectively, p < 0.05). D + C resulted in a more follicles > 16 mm during IUI cycles (3.3 ± 2.3 versus 2.9 ± 2.2, respectively, p = 0.01), while lower mean total gonadotropin dosage was administered after D + C supplementation compared with D (3414 ± 1141 IUs versus 3877 ± 1143 IUs respectively, p = 0.032) in IVF cycles. Pregnancy and delivery rates were similar for both IUI and IVF.

CONCLUSION

D + C significantly increases AFC and improves ovarian responsiveness during IUI and IVF without a difference in clinical outcome.

Does local injury to the endometrium before IVF cycle really affect treatment outcome? Results of a randomized placebo controlled trial

AIM

To evaluate the effect of local injury to the endometrium during spontaneous menstrual cycles before in vitro fertilization (IVF) treatment on implantation and pregnancy rates in women with recurrent implantation failure (RIF).

METHODS

In a prospective randomized controlled trial (RCT), a total of 36 patients, with RIF undergoing IVF, were randomized to two groups. In 18 patients, endometrial biopsies were performed using a pipelle curette on days 9-12 and 21-24 of the menstrual cycle preceding IVF treatment. In 18 control patients, a cervical pipelle was performed.

RESULTS

The implantation rate (2.08% versus 11.11%; p = 0.1), clinical (0% versus 31.25%; p < 0.05) and live births rates (0% versus 25%; p = 0.1) were lower in the experimental group compared with controls.

CONCLUSION

Our RCT did not find any benefit from local injury to the endometrium in women with a high number of RIFs. Further studies are warranted to better define the target population of patients who may benefit from this procedure.

Electroejaculation combined with intracytoplasmic sperm injection in patients with psychogenic anejaculation yields comparable results to patients with spinal cord injuries

OBJECTIVE

To evaluate sperm quality and fertility potential of men with psychogenic anejaculation treated by electroejaculation (EEJ) and intracytoplasmic sperm injection (ICSI). Treatment results were compared to spinal cord injured (SCI) patients treated similarly.

DESIGN

Retrospective clinical study.

SETTING

Academic tertiary referral fertility center.

PATIENT(S)

Couples with isolated psychogenic anejaculation or SCI.

INTERVENTION(S)

Electroejaculation and ICSI.

MAIN OUTCOME MEASURE(S)

Semen analysis, fertilization rate, implantation rate, pregnancy rate, delivery rate and safety of the procedure.

RESULT(S)

Fifteen patients diagnosed with psychogenic anejaculation underwent 40 EEJ/ICSI cycles. The semen retrieved was characterized by low motility (mean 10.7% ± 12.3%), normal volume (2.2 ± 1.9 mL) and normal count (25.1 ± 29.9 × 10(6)/mL), according to World Health Organization criteria. Results of EEJ/ICSI were compared with 22 SCI patients treated by 66 EEJ/ICSI cycles during the same period. Mean female age and the number of oocytes retrieved per cycle were similar between the groups. Similar semen parameters after EEJ were found between psychogenic and SCI patients. Fertilization rate was significantly lower in the psychogenic patients compared to SCI (47.0% and 57.0%, respectively). No significant differences were found regarding pregnancy rates (20% and 22.7%, respectively), implantation rate (10.2% and 11.6%, respectively) or delivery rates (15% and 18.2%, respectively).

CONCLUSION(S)

Sperm retrieved by EEJ is characterized by asthenospermia and normal count. In spite of the lower fertilization rate in psychogenic patients, combination of EEJ and ICSI gives adequate results to couples with psychogenic anejaculation similar to the results obtained for SCI patients. Current results give these couples a reasonable chance of pregnancy achievement.

Follicular-fluid anti-Mullerian hormone concentrations are predictive of assisted reproduction outcome in PCOS patients

Serum anti-Mullerian hormone (AMH) concentrations constitute a sensitive marker for ovarian ageing. In addition, concentrations of AMH in the follicular fluid constitute a useful marker of embryo implantation in assisted reproduction cycles. The present study measured serum and follicular-fluid AMH concentrations on the day of oocyte retrieval. These data showed that clinical pregnancy rates (25.0, 34.1 and 42.1%, respectively, P < 0.001), embryo implantation rates (24.3, 35.0 and 44.4%, respectively, P < 0.001) and fertilization rates (59.2, 70.9 and 79.5%, respectively, P < 0.001) were markedly different among the low, moderate and high follicular-fluid AMH groups but not among the different serum AMH concentration groups. Follicular-fluid AMH concentrations were negatively correlated with follicular-fluid oestradiol concentrations. The results of this study suggest that follicular-fluid AMH concentration on the day of oocyte retrieval would appear to better reflect the reproductive outcome in PCOS patients undergoing assisted reproduction.

Elevated day 3 FSH/LH ratio due to low LH concentrations predicts reduced ovarian response

Adequate ovarian response, essential for successful IVF, cannot be accurately predicted. This study retrospectively reviewed all patients undergoing IVF from 1998 to 2001. Inclusion criteria were age <41 years at treatment onset and a basal day 3 serum FSH concentration <12 IU/l. Women with FSH <or=8 IU/l underwent a secondary analysis. Two groups emerged according to basal day 3 serum FSH/LH ratio: >or=3 in group 1 and <3 in group 2 (controls). Age at treatment initiation, basal serum day 3 FSH and LH concentrations, peak serum oestradiol concentration, number of retrieved and fertilized oocytes and pregnancy rate were analysed. Groups 1 (n = 41, 111 IVF treatment cycles) and 2 (n = 596, 1,434 IVF treatment cycles) were similar in term of woman's mean age. Group 1 had significantly higher mean basal day 3 FSH concentration (P < 0.01) and significantly lower oestradiol concentrations at oocyte retrieval (P < 0.01), mean number of oocytes retrieved and fertilized (P < 0.01) and pregnancy rate (P = 0.016). The same trend persisted after excluding 98 patients with basal FSH concentrations >8 IU/l. In conclusion, elevated day 3 FSH/LH ratio is associated with an inferior outcome in IVF treatment cycles and may be used as an additional predictor for decreased ovarian response.

Safety of IVF under anticoagulant therapy in patients at risk for thrombo-embolic events

The objective of this study was to assess the safety of induction of ovulation and oocyte retrieval in patients at risk of thrombosis, necessitating treatment with anticoagulants. Twenty-four patients considered as high risk for a thromboembolic event underwent 73 IVF cycles and 68 oocyte retrieval procedures, and were treated concomitantly with anticoagulation therapy (low molecular weight heparin; LMWH). A subgroup of five patients considered at especially high risk for thrombosis was isolated. These patients were prepared for oocyte retrieval using a controlled spontaneous cycle. All these patients were programmed exclusively for surrogacy. Nineteen women underwent 49 cycles of ovulation induction with gonadotrophins. The average peak oestradiol concentration was 1791 +/- 1420 pg/ml with an average of 13.5 +/- 8.4 oocytes retrieved in each cycle. The five patients from the very high risk group underwent 24 cycles: the average peak oestradiol concentration was 163 +/- 98 pg/ml. In 18, an egg was retrieved and in 14, fertilization was achieved. No bleeding or thromboembolic complications were noted during treatment of both groups of patients. It is concluded that during induction of ovulation in patients at risk for thrombosis, the introduction of LMWH as a cycle protective treatment was not associated with any medical complication. The use of a controlled spontaneous cycle with LMWH is suggested in very high risk patients.

Cumulative live birth rate following in vitro fertilization: study of 5,310 cycles

Most previous studies that calculated cumulative delivery rates following in vitro fertilization (IVF) treatments were limited in the number of cycles and the implementation of intracytoplasmic sperm injection (ICSI). Therefore, we assessed the yield of high-order consecutive IVF treatments (up to 14 consecutive cycles) with and without ICSI. Data from IVF cycles performed in a single center were retrieved from a computerized database. A total of 5,310 cycles among 1,928 patients were evaluated and cumulative delivery rates until the first delivery were calculated using life-table analyses. There were 1,126 pregnancies resulting in 689 live births. Cumulative delivery rates reached 87% following 14 consecutive cycles. Cumulative delivery rates were higher following ICSI compared with cycles without (92.7% vs. 85.4%). In conclusion, each treatment cycle increased the cumulative delivery rate, resulting in a rate of 87% after 14 consecutive cycles. The introduction of ICSI resulted in the highest cumulative rates.

Factors predicting IVF treatment outcome: a multivariate analysis of 5310 cycles

The objective of this study was to analyse factors predicting live birth rate following IVF. A computerized database of 1928 women who underwent 5310 consecutive IVF cycles in a single IVF unit was evaluated. Data on the women's age, number of retrieved oocytes, performance of intracytoplasmic sperm injection (ICSI), aetiology of infertility, number of transferred embryos and option of choosing embryos for transfer were evaluated. There were 1126 pregnancies that resulted in 689 live births. Transferring two embryos doubled the chances of delivery compared with one embryo, but transferring three embryos was not significantly superior to two embryos. Moreover, following a three-embryo transfer, the multiple delivery rates were significantly higher (P < 0.01) compared with transferring two embryos. Optimal delivery rates were observed in women aged 26-30 years, with gradual decline with advanced age. The performance of ICSI resulted in higher delivery rates compared with conventional insemination. According to these data, the best live birth results following IVF treatment were achieved when the maternal age was 26-30 years, in couples with male factor infertility undergoing ICSI, and when two embryos were transferred.

Monozygotic twinning is not associated with zona pellucida micromanipulation procedures but increases with high-order multiple pregnancies

Between January 1, 1995 and December 31, 2001, 5,310 cycles were performed in the IVF Unit, Sheba Medical Center, Israel, resulting in 1,066 clinical pregnancies. There was no difference in the rate of pregnancies containing monozygotic twins after zona pellucida micromanipulation procedures (0.9%) compared to conventional insemination (1.0%) (6/677 vs. 4/389).

Cancer incidence in a cohort of infertile women who underwent in vitro fertilization

OBJECTIVE

To assess whether ovarian hyperstimulation and IVF increase the risk for cancer.

DESIGN

Historical cohort analysis. SETTING; IVF units of two medical centers in Israel.

PATIENT(S)

Five thousand twenty-six women who underwent IVF between 1981 and 1992. INTERVENTION(S); Cancer incidence rates were determined through linkage to the National Cancer Registry and were compared with expected rates with respect to age, sex, and place of birth.

MAIN OUTCOME MEASURE(S)

Development of cancer.

RESULT(S)

Twenty-seven cases of cancer were observed, and 35.6 were expected (standardized incidence ratio, 0.76 [95% CI, 0.50-1.10]). Eleven cases of breast cancer were observed, whereas 15.86 were expected (standardized incidence ratio, 0.69 [95% CI, 0.46-1.66]). One case of ovarian cancer and 1 case of cervical cancer were observed, compared with 1.74 and 1.73 cases expected, respectively. The type of infertility, number of IVF cycles, and treatment outcome did not significantly affect risk for cancer.

CONCLUSION(S)

In a cohort of women treated with IVF, no excess risk for cancer was noted.

Evaluation and treatment of low responders in assisted reproductive technology: a challenge to meet

PURPOSE

To investigate the various methods of evaluation and treatment of patients with a low response to controlled ovarian hyperstimulation in assisted reproductive technologies (ART).

METHODS

Review and analysis of relevant studies published in the last decade, identified through the literature and Medline searches.

RESULTS

While a universally accepted definition for low responders is still lacking, these patients are reported to represent about 10% of the ART population. Several ovarian reserve screening techniques have been proposed; however, currently the best-characterized and most sensitive screening tools available are the basal day 3 serum follicle-stimulating hormone level and the clomiphene citrate challenge test. When abnormal, these tests allow physicians to counsel patients that their prognosis for conception is poor. Although the presence of a normal result does indicate better long-term chances for conception, on age-related decline in fecundity remains and patient age should still be considered when counseling patients with normal screening results. Several stimulation protocols have been applied in the low-response group with varying success. Recent studies show that the use of a minidose gonadotropin-releasing hormone-agonist protocol may result in significantly decreased cycle cancellations as well as increased clinical and ongoing pregnancies, and thus is proposed as a first-line therapy. Studies evaluating supplementary forms of treatment to the ovulation induction regimen show improved outcome when pretreating with oral contraceptives, whereas there seems to be no benefit from cotreatment with growth hormone or glucocorticoids. Blastocyst culture and transfer and assisted hatching in low responders are still under evaluation, whereas natural cycle in vitro fertilization may be used in cases of repeated failures as a last option before resorting to oocyte donation or adoption. Future possible forms of treatment like in vitro maturation of immature human oocytes, cytoplasm, and nuclear transfer currently are experimental in nature and their efficacy has still to be proven.

CONCLUSIONS

The evaluation and treatment of low responders in ART remains a challenge. Understanding of the underlying etiology and pathophysiology of this disorder may help the clinician to approach it successfully.

Effects of gonadotrophin-releasing hormone agonists on human ovarian steroid secretion in vivo and in vitro-results of a prospective, randomized in-vitro fertilization study

The aim of this prospective randomized study was to compare the effects of two gonadotrophin-releasing hormone (GnRH) agonists, buserelin and triptorelin, on human ovarian follicular steroidogenesis, oocyte fertilization and IVF treatment outcome. Ovulatory, healthy women undergoing IVF were treated either with human menopausal gonadotrophin (HMG) alone or with HMG and one of the two GnRH agonists. Serum and follicular fluid hormonal concentrations and cultures of luteinizing granulosa cells obtained during follicular aspiration were analysed. GnRH agonist treatment significantly affected steroidogenesis both in serum and follicular fluid. In follicular fluid, progesterone and oestradiol concentrations were significantly elevated while testosterone concentrations were significantly lower in the triptorelin group. The ratios of testosterone/progesterone, oestradiol/progesterone but not oestradiol/testosterone concentrations were significantly affected by GnRH agonist administration. Similarly, the steroidogenic activity of luteinizing granulosa cells in vitro was significantly decreased in women treated with GnRH agonists. Women treated with GnRH agonists had significantly more fertilized oocytes and cleaving embryos. The results indicate a marked effect of GnRH agonists on the pattern of ovarian follicular steroidogenesis that cannot be explained solely by changes in gonadotrophin concentrations.

Incidence and perinatal outcome of multiple pregnancies after intracytoplasmic sperm injection compared to standard in vitro fertilization

PURPOSE

Our purpose was to assess the incidence of multiple pregnancies and their obstetric outcome after intracytoplasmic sperm injection.

METHODS

The study group comprised women who delivered twins or triplets after intracytoplasmic sperm injection and standard in vitro fertilization. The incidence and main perinatal outcome of 140 multiple pregnancies resulting from intracytoplasmic sperm injection or standard in vitro fertilization treatment were analyzed.

RESULTS

A total of 60 multiple pregnancies was obtained after intracytoplasmic sperm injection (3.4 +/- 1.1 embryos/cycle) and 80 after standard in vitro fertilization (3.3 +/- 2.0 embryos/cycle). The incidence of multiple pregnancy, i.e., 22.6 compared to 20.7%, respectively, was calculated. The obstetric outcome of 47 multiple pregnancies after intracytoplasmic sperm injection was 39 twin deliveries at between 27 and 37 weeks of gestation (mean, 36 +/- 3.3) and 8 successful triplet deliveries between 26 and 36 weeks of gestation (mean 32.6 +/- 2.4). The outcome after regular in vitro fertilization was similar. No major malformations were observed.

CONCLUSIONS

The results of this study showed that the incidence of multiple pregnancies after intracytoplasmic sperm injection was similar to that after standard, conventional in vitro fertilization. The perinatal outcome did not differ between both groups.

Oocyte quality and treatment outcome in intracytoplasmic sperm injection cycles of polycystic ovarian syndrome patients

Patients with polycystic ovarian syndrome (PCOS) have higher miscarriage rates. It is postulated that this is caused by a lower rate of mature oocytes, and a lower quality of embryos. Retrospectively we analysed 51 intracytoplasmic sperm injection (ICSI) cycles of 31 PCOS patients. These data were compared to age-matched controls (105 cycles) during the same period. All patients of both groups received gonadotrophin-releasing hormone (GnRH) agonists prior to gonadotrophin treatment. The rate of metaphase II oocytes (MII) was not different. However, the mean absolute number of normally fertilized oocytes was significantly higher in PCOS patients (5.00 versus 3.56, P < 0.01), due to a higher number of oocytes retrieved. More embryos were transferred by cycle in the PCOS group (2.69 versus 2.17, P < 0.05), with a higher cumulative embryo score. The overall and multiple pregnancy rate showed no differences and the clinical abortion rate was lower (21 versus 41.67%, P < 0.05) in the controls. Our findings demonstrate that negative factors unconnected to oocyte morphology must be present in PCOS patients. It is possible that only cytoplasmic, not nuclear, maturity is influenced in these patients.

Analytical and clinical evaluation of the Immulite® estradiol assay in serum from patients undergoing in vitro fertilization: estradiol increase in mature follicles

We examined an immunoassay for estradiol (E2) on the Immulite®—an automated, random access chemiluminescent immunoassay system—to determine its accuracy and precision required for in vitro fertilization (IVF) studies. The assay, which has a reportable range from 73 to 7300 pmol/L, demonstrated good linearity under dilution, a detection limit of 44 pmol/L, and interassay CVs of 12.6% and 7.6% at 466 and 6164 pmol/L, respectively. In a retrospective analysis of 545 serum samples, the assay showed adequate agreement with an antibody-coated-tube RIA. The two E2 assays showed good agreement, even on samples from patients receiving a variety of different estrogen replacement therapies. Longitudinal studies of individual IVF cycles showed good parallelism between the automated system and the RIA, and results by the automated assay correlated well with the total number of follicles.

Long gonadotrophin releasing hormone agonist/human menopausal gonadotrophin protocol for ovarian stimulation in intrauterine insemination treatment

OBJECTIVE

This prospective study was undertaken to examine the usefulness of a long gonadotrophin releasing hormone agonist (GnRH-a)/human menopausal gonadotrophin (hMG) protocol in intrauterine insemination (IUI) treatment. The results were compared to those of clomiphene citrate (CC)/hMG/IUI.

STUDY DESIGN

Seventy-five patients were recruited to a GnRH-a/hMG group (group 1) while 88 patients underwent CC/hMG stimulation and served as controls (group 2). The study subjects were stimulated with a long GnRH-a/hMG regimen. IUI was performed 36 h after the administration of human chorionic gonadotrophin.

RESULTS

The number of preovulatory follicles, the thickness of endometrium and sperm parameters were similar in both groups. The hMG requirements were significantly higher in group 1 than in group 2 (21.2 +/- 5.1 vs. 8.1 +/- 3.1 ampoules). The pregnancy rate was 20% in group 1 and 12.5% in group 2, the difference being not significant.

CONCLUSION

The pregnancy rates were not significantly different between the GnRH-a/hMG/ IUI and CC/hMG/IUI groups. In addition, GnRH-a/hMG stimulation is notably more expensive than CC/hMG, and for these reasons, GnRH-a/hMG stimulation is not cost-effective in routine IUI therapy.

Relationship of timing of agonist administration in the cycle phase to the ovarian response to gonadotropins in the long down-regulation protocols for assisted reproductive technologies

OBJECTIVE

To assess whether the ovarian response to exogenous gonadotropins and cycle performance is affected by different timing of an agonist administration in long down-regulation protocols.

DESIGN

An agonist was administered irrespective of cycle phase, with exogenous gonadotropin beginning 15 days later.

PATIENTS

Five hundred fifty-seven normovulatory infertile patients, aged < or = 38 years, were classified into seven study groups, depending on the phase of the cycle in which agonist was started.

MAIN OUTCOME MEASURES

Endocrine profile, amount of exogenous stimulation, occurrence of ovarian cysts, mean number of oocytes recovered and embryos transferred, pregnancy rate, implantation rate, and live-birth rate of the seven groups.

RESULTS

The ovarian response of the groups did not show any statistically significant differences in relation to the initiation of the agonist. The only effect was a different incidence of ovarian cyst formation, but this phenomenon did not affect cycle performance. The pregnancy, implantation, and live-birth rates showed differences that did not reach statistical significance.

CONCLUSION

Agonists initiation can be programmed in advance irrespective of the phase of the cycle. This approach can be of help for the logistics of assisted reproduction programs.

Surgically induced ovulation in the polycystic ovary syndrome: wedge resection revisited in the age of laparoscopy

OBJECTIVE

To provide an up-to-date comprehensive review of published data on laparoscopic methods of ovulation induction in the polycystic ovary syndrome (PCOS). Areas to be considered include the historical background of these procedures, their outcomes as reported in the literature, and their potential adverse effects. Through the careful review of these issues, some recommendations for clinical use and further study are offered.

DESIGN

Relevant studies were identified through a the search of a computerized bibliographic database of holdings in the National Library of Medicine as well as the manual scanning and cross-referencing of relevant medical journals.

RESULTS

Twenty-nine relevant studies were identified in the English language literature. These studies consist almost exclusively of uncontrolled case series. Pregnancies after laparoscopic ovulation induction procedures have been reported in an average of 55% of treated subjects (range 20% to 65%). Potential advantages of laparoscopic ovulation induction over gonadotropin therapy may include possible cost savings, serial repetitive ovulatory events resulting from a single treatment, no increased risk of ovarian hyperstimulation or multiple gestation, and the prospect for a higher live birth rate owing to a seemingly lower incidence of miscarriage. Reported adverse effects include a high rate of intra-abdominal adhesion formation and a single case of iatrogenic premature menopause due to postoperative ovarian atrophy.

CONCLUSIONS

The available circumstantial evidence suggests that laparoscopic procedures designed to induce ovulation may be of value in the PCOS subject who, despite an exhaustive trial of clomiphene citrate therapy, remains anovulatory and is unable or unwilling to undergo gonadotropin therapy. However, because of the risks of postoperative ovarian adhesions, carefully constructed controlled trials must be performed before these procedures can be viewed as efficacious and safe.

Clomiphene citrate and hMG: an alternative stimulation protocol for selected failed in vitro fertilization patients

PURPOSE

This study was carried out to evaluate the potential role of the combination clomiphene citrate/human menopausal gonadotropin (CC/hMG) for patients who failed previous in vitro fertilization (IVF) attempts with gonadotropin-releasing hormone analogs (GnRH-a) and/or exogenous gonadotropins.

METHODS

Patients were stimulated with CC/hMG (n = 93) after unsuccessfully undergoing 182 gonadotropin cycles with (n = 106) or without (n = 76) luteal-phase GnRH-a. Cancellation rate, length of stimulation, and peak estradiol levels did not differ significantly between the two regimens.

RESULTS

Although fewer oocytes were retrieved when the CC/hMG combination was used, 16 patients were able to successfully achieve a pregnancy (26.2% delivery rate/transfer). When daily follicle stimulating hormone (FSH) levels were measured in two successive cycles in those women who conceived with the CC/hMG stimulation, baseline levels did not differ when compared with a previous GnRH-a/hMG cycle. Nevertheless, serum FSH levels rose rapidly and remained higher in the GnRH-a/hMG cycle, reaching significantly higher levels on day of human chorionic gonadotropin (hCG) administration.

CONCLUSION

Selected patients who failed previous IVF attempts with gonadotropins with or without GnRH analogs may benefit from the addition of CC to their ovarian stimulation protocol.

The significance of serum progesterone levels on the day of hCG administration on IVF pregnancy rates

The aim of the present study was to evaluate the relationship between serum progesterone level on the day of human chorionic gonadotropin (hCG) administration (day 0) and pregnancy rate among patients undergoing in vitro fertilization and embryo transfer. Serum progesterone levels were analyzed retrospectively in 160 cycles. In 56 women ovarian stimulation was induced by gonadotropins only (group A). In 104 cases a gonadotropin releasing hormone (GnRH) analog was given prior to gonadotropin administration (group B). At least three embryos were transferred in all cases. A significantly (p < 0.01) higher serum progesterone level (> or = 1 ng/ml) on day 0 was observed in the 43 patients of group A who did not conceive compared with the 13 who conceived. No significant difference in serum progesterone levels on day 0 was found between the 37 patients of group B who conceived and the 67 who did not. The pregnancy rate (0.36) in group B was significantly (p < 0.05) higher than that in group A (0.23). However, the pregnancy rate (0.35) in patients in group A with low progesterone levels (< or = 1 ng/ml) was not significantly lower than that in group B. We demonstrated that elevated progesterone levels (> or = 1 ng/ml) on day 0 in patients receiving stimulation with gonadotropin only, might be detrimental to pregnancy. In view of these results, we suggest that early oocyte retrieval should be considered in patients whose progesterone level on the day of hCG administration exceeds 1 ng/ml following stimulation with gonadotropin only.