The significance of delayed suppression using buserelin acetate and recombinant follicle-stimulating hormone in a long protocol in vitro fertilization program

Decline in Female Fertility After 40 Years

Important factor related to the conception possibility is women age. The decline in fertility with aging is proven and evident in literature. Infertility is increasing and many couples seek help in advanced techniques such as IVF (in vitro fertilization) in order to overcome the problem caused by aging, but the quality of the oocytes is a significant limiting factor. With the aging the quantity and quality of oocytes decreases, such as the quality of the embryo after fertilization. The accelerated rhythm of life, liberty and women inclusion in all kinds of professions brought many benefits to women, but also increasingly postponing births. Each person is unique individual, and can be more or less fertile compared to the average at same age. Unfortunately, some women has a rapid decline in fertility - accelerate aging, very early, already in the early twenties and when testing them with different methods and exams, the result is very low number of oocytes, low value of anti-Müllerian hormone and also very poor quality of these oocytes, or low ovarian reserve. The problem is that when you have accelerate aging, even IVF techniques can not be of great help in achieving pregnancy. The pregnancy rate (17,65%) and the childbirth rate (5,88%) with the patients older than 40 is very low, although comparable to the data from the scientific literature and speaks in favour of the fact that the success of assisted reproductive techniques is very modest with women older than 44.

Prognostic factors associated with clinical pregnancy in in vitro fertilization using pituitary down-regulation with depot and daily low-dose luteal phase gonadotropin releasing hormone agonists: A single center's experience

AIM:

To review the experience on depot-dose, and daily low-dose gonadotropin releasing hormone agonist (GnRHa) long protocols and identify prognostic factors.

SETTING AND DESIGN:

A chart review was conducted on 2106 depot and 1299 daily low-dose cycles at a university hospital.

METHODS:

Clinical parameters were summarized, and prognostic factors of clinical pregnancy for each protocol were identified by logistic regressions. Missing data were imputed using multiple imputations (MI) and the regression models were rerun after MI.

RESULTS:

Clinical pregnancy rate was 57.5% and 46.9% in the depot and daily low-dose groups, respectively. Logistic regressions with MI identified age (odds ratio [OR]: 0.95, 95% confidence interval [CI]: 0.92–0.98), serum progesterone (OR: 0.62, 95% CI: 0.45–0.84) and endometrial thickness (OR: 1.06, 95% CI: 1.02–1.12) on human chorionic gonadotropin (hCG) day, number of oocytes retrieved (OR: 1.04, 95% CI: 1.01–1.06), fertilization rate (OR: 2.66, 95% CI: 1.46–4.87) and ratio of good-quality D3 embryos (OR: 4.31, 95% CI: 2.79–6.67) as prognostic factors in the depot group. Age (OR: 0.95, 95% CI: 0.92–0.98), endometrial thickness on hCG day (OR: 1.09, 95% CI: 1.03–1.15), ratio of good quality D3 embryos (OR: 2.56, 95% CI: 1.59–4.13) and the number of cryopreserved embryos (OR: 1.07, 95% CI: 1.003–1.15) are prognostic for the daily low-dose protocol. Some regression coefficients that are significant under model-wise deletion become nonsignificant after MI.

CONCLUSIONS:

Age, embryo quality and endometrial thickness on hCG day are important prognostic factors for both 1.0/1.3 mg depot and 0.05/0.1 mg daily low-dose luteal phase GnRHa long protocols. MI is a valuable tool to gauge and address bias caused by missing data in reproductive medicine.

Effect of delayed initiation of gonadotropin in luteal long protocol on in vitro fertilization

OBJECTIVE

To evaluate whether delayed initiation of gonadotropin in luteal long protocol affected the outcome of in vitro fertilization (IVF).

STUDY DESIGN

Prospective randomized study at the reproductive centre of a university-based hospital. Eighty-five subfertile women undergoing IVF embryo transfer after a standardized gonadotropin-releasing hormone agonists (GnRHa) long protocol. The patients were randomized into group A (stimulated 3 weeks after GnRHa administration) and group B (stimulated 2 weeks after GnRHa administration), according to the time of gonadotropin initiation after GnRHa-mediated pituitary suppression. The main outcome measures were clinical pregnancy and live birth rates.

RESULTS

There were no significant differences in baseline characteristics such as age, body mass index and basal follicle-stimulating hormone (bFSH) between the two groups. In group B, the days of gonadotropin stimulation were significantly greater than that in group A (p < 0.05), while the total dose of gonadotropin in group A was comparable to that in group B. Serum luteinizing hormone was lower and follicle-stimulating hormone higher in group A than in group B (p < 0.05) on initiation day. There were no significant differences in hormone profile measurements between the two groups. Moreover, the clinical pregnancy rate, implantation rate, live birth rate, miscarriage rate and moderate ovarian hyperstimulation syndrome rate were not significantly different between the groups.

CONCLUSION

Delay of gonadotropin stimulation in a standard long protocol may increase clinical efficiency, without significantly changing clinical outcome.

What is the optimum maximal gonadotropin dosage used in microdose flare-up cycles in poor responders?

OBJECTIVE

To find out the optimum maximal dosage of recombinant follicle stimulating hormone (rFSH) in microdose gonadotropin-releasing hormone analog (GnRH-a) flare cycles in poor responders.

DESIGN

Prospective randomized study.

SETTING

Private infertility clinic.

PATIENT(S)

A total of 119 women were taken into the study.

INTERVENTION(S)

The study group underwent a microdose protocol with a GnRH-agonist followed by rFSH administration. On the third day of GnRH-a administration, 119 patients were randomized in three groups to receive daily fixed doses of 300 IU of rFSH (group A, n = 38), or 450 IU of rFSH (group B, n = 39), or 600 IU of rFSH (group C, n = 42).

MAIN OUTCOME MEASURE(S)

Peak E(2) levels, days of stimulation with rFSH, total rFSH dosage, total number of oocytes retrieved, M2 oocytes retrieved, total number of embryos, number of embryos transferred, number of Grade-1 embryos transferred, clinical pregnancy rate (positive fetal cardiac activity), and cancellation rates of stimulation and embryo transfer.

RESULT(S)

Clinical pregnancy rates were 13.1%, 15.3%, and 16.1% for group A, group B, and group C, respectively. There were no significant differences in the age, peak serum E(2) concentration, days of stimulation with rFSH, total number of M2 oocytes retrieved, number of embryos transferred, clinical pregnancy rates, and cancellation rates of stimulation and embryo transfer between the three groups except for total rFSH dosage.

CONCLUSION(S)

There is no need to use doses above 300 IU of rFSH to increase the pregnancy rate in microdose cycles. In addition, because the duration of stimulation does not differ between the groups, the usage of 300 IU rFSH in microdose cycles results in less total amount of rFSH consumed in a cycle compared with higher dosages, and this would obviously cost less money to the patients.

Ovarian reserve

As a result of temporary social trends, many women elect to postpone their first pregnancy to a later stage in life. A large part of this population will be infertile by the time they opt to conceive, mainly because of a decreasing ovarian reserve and low oocyte quality resulting from age. Aging oocytes have been widely suggested to be the major cause for the decline in fertility. In a subfertile population, the availability of an accurate screening test of ovarian reserve would provide a valuable means of predicting the chances of pregnancy and live birth with or without treatment and selecting an optimal dose of ovarian stimulation where treatment using ovarian stimulation is planned. The following hormonal markers and ultrasound parameters have been used to attempt to estimate ovarian reserve and predict those with a poor chance of success in assisted reproductive techniques: age; concentrations of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, inhibin, anti-Müllerian hormone; ovarian volume, ovarian antral follicle count; and ovarian biopsy. Further studies have introduced the use of dynamic tests-using gonadotropin-releasing hormone agonist, FSH, or clomiphene citrate-to assess ovarian function. The use of a wide range of tests suggests that no single test provides a sufficiently accurate result. But the simultaneous evaluation of a combination of tests could be used as a marker of diminished ovarian reserve and a sensitive predictor of response to ovarian stimulation in patients undergoing in vitro fertilization treatment.

Ovarian reserve tests for predicting fertility outcomes for assisted reproductive technology: the International Systematic Collaboration of Ovarian Reserve Evaluation protocol for a systematic review of ovarian reserve test accuracy

BACKGROUND

The presence of a wide range of tests of ovarian reserve suggests that no single test provides a sufficiently accurate result. Many tests are used without reference to an evidence base. So far, individual studies conducted on these tests are too small to give precise estimates of prognostic accuracy.

OBJECTIVES

To systematically assess the accuracy of the available tests of ovarian reserve in terms of prediction of fertility outcomes.

SEARCH STRATEGY

The search will be conducted using the name of the respective index test being studied (as listed on the MESH database), if more than 2000 citations are listed, 'ovary' and or 'ovarian', 'fertility' and or 'reserve' will be combined with the original search term as required. Studies of the accuracy of tests of ovarian reserve will be obtained without language restrictions from 1980 to 2005 using the following electronic databases and Ovid software: MEDLINE, EMBASE, PUBmed, Biological extracts, Pascal, Cochrane Library (CDSR, DARE, CCTR, HTA), Best Evidence databases, SCISEARCH, Conference Proceedings (ISI Proceedings, Healthstar, Current Contents, Science Citation Index, Cancerlit and Econlit and NHS Economic Evaluation database. The National Research Register, the Medical Research Council's Clinical Trials Register, MEDION, DARE, and the US Clinical Trials register.

SELECTION CRITERIA

Studies will be selected if accuracy of tests are compared with a reference standard and include data that can be abstracted into a two-by-two table to calculate sensitivity and specificity. The studies to be included in this review will examine one of the following index 'tests' within a study population of women undergoing assisted reproductive technology: * Clinical variables--age, history of cancelled cycles. * Basal blood tests--follicle-stimulating hormone (FSH), lutenising hormone (LH), FSH:LH ratios, estradiol (E(2)), inhibin A and B, progesterone (P(4)), P(4):E(2) ratios, antimullerian hormone, testosterone, vascular endothelial growth factor, insulin-like growth factor-1:insulin-like growth factor binding protein-1 ratios. * Dynamic tests--clomiphene citrate challenge test, gonadotropin analogue stimulating test, exogenous FSH ovarian reserve test. * Ultrasound tests-antral follicle count, ovarian volume, ovarian stromal peak systolic velocity, including waveform and pulsatility index, ovarian follicular vascularity. * Histology--ovarian biopsy. Data collection and analysis Two independent reviewers will perform quality assessment and data extraction. Prognostic accuracy will be determined by calculating positive and negative likelihood ratios for the following outcomes or reference standards: live birth, ongoing pregnancy, clinical pregnancy, biochemical pregnancy, embryos available for transfer, eggs obtained at oocyte retrieval, cycles cancelled prior to oocyte retrieval. Main results and conclusions N/A.

Randomized trial to compare the effect of recombinant human FSH (follitropin alfa) with or without recombinant human LH in women undergoing assisted reproduction treatment

Women undergoing intracytoplasmic sperm injection (ICSI) for male factor infertility were randomly assigned to receive ovarian stimulation in a long agonist protocol with a combination of recombinant human FSH (r-hFSH; Gonal-F) and recombinant human LH (r-hLH; Luveris) (n = 212) starting on day 6 of FSH stimulation until human chorionic gonadotrophin (HCG) at a daily fixed dose of 150 IU r-hLH, or with r-hFSH alone (n = 219). There was no significant difference in the number of metaphase II oocytes retrieved (10.3 versus 10.4) in patients treated with r-hFSH and r-hLH versus r-hFSH alone; however, more embryos were transferred in the LH-supplemented group (2.9 versus 2.8, P = 0.037). Overall, the implantation rates were 22.9 versus 27.0% in patients treated with r-hFSH and r-hLH versus with r-hFSH alone respectively (NS). The respective numbers of MII oocytes retrieved in patients <35 or >or=35 years were 11 versus 8.3 (P = 0.010) for patients treated with r-hFSH alone, and 10.7 versus 9.3 (NS) for those given supplemental r-hLH (150 IU) from day 6. Implantation rates in patients <35 years treated with r-hFSH were higher (30.7%) than those receiving r-hFSH and r-hLH, (23.5%) (P = 0.068). In patients >or=35 years, the implantation rates were 21.7% for those patients supplemented with 150 IU r-hLH from day 6 of stimulation versus 15.7% when treated with FSH alone (NS). Younger patients therefore do not seem to benefit from an LH-supplemented ovarian stimulation protocol, but women >or=35 years undergoing assisted reproduction may benefit from using r-hLH in addition to r-hFSH.

GnRH antagonists in normal- responder patients

To review the use of GnRH antagonists in normal-responding patients who are undergoing infertility treatment. Review article and case studies.For the normal-responding patient, GnRH antagonist protocols provide equivalent outcomes as GnRH agonist protocols, with the added patient benefit of significantly fewer treatment/injection days. In addition, a decrease or plateau in E(2) on the day after initiation of the GnRH antagonist has no prognostic significance in IVF outcome.For normal-responding patients, a GnRH antagonist can be used in a flexible fashion to achieve high success rates. The lack of correlation between E(2) patterns on the day after initiation of a GnRH antagonist and IVF outcomes supports the concept that no intervention (such as LH add-back) is necessary to guard against an early decrease or plateau during stimulation with recombinant FSH and a GnRH antagonist. Clinicians must consider ovarian physiology and the mechanism of GnRH antagonist action in patient management.

Rescue of IVF cycles by HMG in pituitary down-regulated normogonadotrophic young women characterized by a poor initial response to recombinant FSH

BACKGROUND

The aim of this study was to investigate the effects of adding human menopausal gonadotrophin (HMG) during controlled ovarian stimulation in normoovulatory normogonadotrophic patients showing an initial suboptimal response to a standardized long protocol therapy with recombinant FSH (rFSH) (300 IU/day).

METHODS

A total of 43 such patients were randomized in two groups. In Group A, 150 IU rFSH was substituted by 150 IU HMG after day 8 of stimulation. The stimulation protocol of Group B involved a simple increase of the daily rFSH dose to 375 IU after day 8. A total of 40 BMI and age matched patients with an optimal ovarian response formed the control group (Group C).

RESULTS

The mean Group A serum concentration of oestradiol on the day of HCG administration and average number of oocytes retrieved were significantly higher than Group B (P < 0.001) and equivalent to Group C. A total of 10 pregnancies (50%) in Group A, 8 (34.8%) in Group B and 19 (47.5%) in the control group were achieved.

CONCLUSIONS

The data suggest that LH supplementation improves the ovarian outcome in patients characterized by an inadequate initial response to rFSH therapy in a long protocol.