Follicular development and hormonal levels following highly purified or recombinant follicle-stimulating hormone administration in ovulatory women undergoing ovarian stimulation after pituitary suppression for in vitro fertilization: implications for implantation potential

Success of frozen embryo transfer: Does the type of gonadotropin influence the outcome?

OBJECTIVES

To determine whether there is a difference in outcome between different ovulation-induced cycles after frozen-thawed embryo transfer (FET).

METHODS

We searched the Cochrane Menstrual Disorders and Subfertility Group's trials register in May 2009, the Cochrane Central Register of Controlled Trials (Cochrane Library, Issue 1, 2008), ISI Web of Knowledge (1985 to August 2009), and reference lists of articles. Relevant conference proceedings were hand-searched and researchers in the field were contacted. Randomized controlled trials and retrospective studies were included, comparing the various cycle regimens and different methods during FET in assisted reproductive technology, ie, in vitro fertilization and intracytoplasmic sperm injection.

RESULTS

Using the agonist long protocol for downregulation, five trials provided extractable data for live-birth rates, ongoing pregnancy, and clinical pregnancy rates following FET. One trial provided extractable data for clinical pregnancy rate. There was no evidence of a significant difference in any outcome between the users of urinary gonadotropins versus recombinant follicle-stimulating hormone. Data on implantation and miscarriage rates following FET were not available for analysis.

CONCLUSIONS

It seems that clinical pregnancy rate after FET is not influenced by the type of gonadotropins used. Research should be directed towards improving freezing and thawing techniques.

Unsuccessful oocyte retrieval: technical artefact or genuine 'empty follicle syndrome'?

Unsuccessful oocyte retrieval after apparently successful ovarian stimulation (also referred to as 'empty follicle syndrome') occurs in 1-7% of women undergoing assisted reproductive techniques. A literature review was performed, as individual studies have reached differing conclusions on the aetiology and treatment or management of the phenomenon. The aetiology is not clear, but probably multifactorial, and occurs in natural and stimulated cycles. In many cases, technical problems such as errors in human chorionic gonadotrophin (HCG) administration or defects in HCG batches can be identified, but this is not sufficient to account for all reported cases. The term empty follicle syndrome is inappropriate in cases in which such procedural factors can be identified. In many patients, however, unsuccessful oocyte retrieval appears to be due to an underlying ovarian dysfunction, and some may have a genuine empty follicle syndrome. Appropriate measures, such as monitoring of serum beta-HCG, should be taken to minimize the risk of unsuccessful oocyte retrieval. This review discusses the potential causes of unsuccessful oocyte retrieval, its clinical implications, and potential solutions to this clinical problem.

Cost-effectiveness of recombinant versus urinary follicle-stimulating hormone in assisted reproduction techniques in the Spanish public health care system

PURPOSE

To evaluate the relative cost-effectiveness of recombinant and urinary follicle-stimulating hormone (FSH) in assisted reproduction techniques in the Spanish National Health Service.

METHODS

Markov modelling was used to compare costs and outcomes of three complete treatment cycles using recombinant or urinary FSH for controlled ovarian stimulation. Cost and effectiveness estimates were obtained from the literature and from Spanish clinicians. A Monte Carlo technique was used to randomise the distribution of outcomes at each stage. The analysis was performed by passing a virtual population of 100,000 patients through the computer simulation in each of 5000 Monte Carlo simulations.

RESULTS

The cost per pregnancy was Euro12,791+/-1202 ($11,346+/-1066) with recombinant and Euro13,007+/-1319 ($11,537+/-1170) with urinary FSH (p < 0.0001). The mean number of cycles per pregnancy was 4.69 and 5.21, respectively.

CONCLUSIONS

Recombinant FSH is more cost-effective than urinary FSH in the Spanish public health care system.

The clinical efficacy and efficiency of a 100-IU starting dose of recombinant follicle stimulating hormone (Puregon) in Korean women undergoing in vitro fertilization and embryo transfer

AIM

A prospective, non-comparative study was conducted to evaluate the efficacy and efficiency of a starting dose of 100 IU recombinant follicle stimulating hormone (rhFSH, Puregon) in women undergoing ovarian stimulation prior to in vitro fertilization (IVF).

METHODS

A total of 40 women were down-regulated with gonadotropin releasing hormone agonist (long protocol), then treated with a fixed dose of 100 IU rhFSH for the first 4 days, and the dose of gonadotropin administration was adjusted according to patient's response thereafter. A maximum number of 3 embryos were transferred in 32 patients.

RESULTS

Nine patients were treated with intracytoplasmic sperm injection, and 24 with conventional IVF. The duration of stimulation was 10.8 +/- 1.8 days, serum estradiol concentration on human chorionic gonadotropin day was 1693.0 +/- 1651.2 pg/mL, and 1480 +/- 450 IU rhFSH was used. A mean number of 8.4 +/- 5.7 oocytes were retrieved, 4.9 +/- 4.3 embryos obtained, 2.4 +/- 0.9 embryos transferred, and 3.5 +/- 3.2 embryos cryopreserved. The proportion of mature oocytes was 71.6%, and the fertilization rate was 86.4%. Clinical pregnancy was achieved in 8 patients (25.0%), and all of these pregnancies are ongoing or delivered. There were 3 cases of twin gestations (37.5%). The implantation rate was 13.1% (11/84). There was one case of moderate ovarian hyperstimulation syndrome, however, the patient recovered within 7 days without any complications.

CONCLUSION

The starting dose of 100 IU rhFSH has a good safety profile, and is adequate in controlled ovarian hyperstimulation for IVF with a small amount of gonadotropin administered.

Reflections on the cost-effectiveness of recombinant FSH in assisted reproduction. The clinician's perspective

PURPOSE

To analyze the relative cost-effectiveness of recombinant FSH (rFSH) and urinary FSH (uFSH) in assisted reproduction techniques (ART).

METHODS

Calculation of the average cost-effectiveness ratio and the incremental cost-effectiveness ratio to compare costs and effects (pregnancy rates) of the two therapeutic options (rFSH and uFSH).

RESULTS

Assuming that the cost of the procedure per ART cycle is between 100,000 pesetas (601 euro) and 150,000 pesetas (901.52 euro), and pricing the GnRH analogues used for pituitary suppression at 35,000 pesetas (210.3 euro), the cost-effectiveness ratio is better for rFSH than for uFSH, implying that the cost per pregnancy is lower when the recombinant preparation is used.

CONCLUSIONS

In ART, the use of rFSH is more cost-effective than uFSH.

Recombinant human follicle-stimulating hormone for ovulation induction in polycystic ovary syndrome: a prospective, randomized trial of two starting doses in a chronic low-dose step-up protocol

PURPOSE

The aim was to compare the follicular response to 37.5 and 50 IU of recombinant follicle-stimulating hormone (FSH) as starting doses for ovulation induction in patients with polycystic ovary syndrome (PCOS).

METHODS

Prospective, randomized, crossover study including 15 women with clomiphene citrate-resistant chronic anovulatory infertility. Patients were treated with subcutaneous recombinant FSH at starting doses of 37.5 IU and 50 IU, respectively, according to a low-dose step-up protocol. Each woman received both treatments, in a randomized order, with an interval of > or = 1 month between treatments.

RESULTS

All treatment cycles were ovulatory after an appropriate follicular response and hormone levels were similar with both treatments, although the total quantity of FSH required and the mean daily dose required to induce identical follicular development were significantly lower with a starting dose of 37.5 IU FSH. The mean duration of treatment to achieve ovulation was approximately 13 days with both treatments but treatment periods > or = 20 days were required in some patients.

CONCLUSIONS

In women with PCOS, a starting dose of 37.5 IU recombinant FSH may be adequate to induce follicular growth. However, the use of low starting doses may result in some cases in increased treatment periods and need for monitoring.