Friendly IVF: the way of the future?

Oral medications including clomiphene citrate or aromatase inhibitors with gonadotropins for controlled ovarian stimulation in women undergoing in vitro fertilisation

BACKGROUND

Gonadotropins are the most commonly used medications for controlled ovarian stimulation in in vitro fertilisation (IVF). However, they are expensive and invasive, and are associated with the risk of ovarian hyperstimulation syndrome (OHSS). Recent calls for more patient-friendly regimens have led to growing interest in the use of clomiphene citrate (CC) and aromatase inhibitors with or without gonadotropins to reduce the burden of hormonal injections. It is currently unknown whether regimens using CC or aromatase inhibitors such as letrozole (Ltz) are as effective as gonadotropins alone.

OBJECTIVES

To determine the effectiveness and safety of regimens including oral induction medication (such as clomiphene citrate or letrozole) versus gonadotropin-only regimens for controlled ovarian stimulation in IVF or intracytoplasmic sperm injection (ICSI) treatment.

SEARCH METHODS

We searched the following databases: Cochrane Gynaecology and Fertility Group Specialised Register (searched January 2017), the Cochrane Central Register of Controlled Trials (CENTRAL CRSO), MEDLINE (1946 to January 2017), Embase (1980 to January 2017), and reference lists of relevant articles. We also searched trials registries ClinicalTrials.gov (clinicaltrials.gov/) and the World Health Organization International Clinical Trials Registry Platform (www.who.int/trialsearch/Default.aspx). We handsearched relevant conference proceedings.

SELECTION CRITERIA

We included randomized controlled trials (RCTs). The primary outcomes were live-birth rate (LBR) and OHSS.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial eligibility and risk of bias. We calculated risk ratios (RR) and Peto odds ratio (OR) with 95% confidence intervals (CIs) for dichotomous outcomes and mean differences (MD) for continuous outcomes. We analyzed the general population of women undergoing IVF treatment and (as a separate analysis) women identified as poor responders. We assessed the overall quality of the evidence using the GRADE approach.

MAIN RESULTS

We included 27 studies in the updated review. Most of the new trials in the updated review included poor responders and evaluated Ltz protocols. We could perform meta-analysis with data from 22 studies including a total of 3599 participants. The quality of the evidence for different comparisons ranged from low to moderate. The main limitations in the quality of the evidence were risk of bias associated with poor reporting of study methods, and imprecision.In the general population of women undergoing IVF, it is unclear whether CC or Ltz used with or without gonadotropins compared to use of gonadotropins along with gonadotropin-releasing hormone (GnRH) agonists or antagonists resulted in a difference in live birth (RR 0.92, 95% CI 0.66 to 1.27, 4 RCTs, n = 493, I2 = 0%, low-quality evidence) or clinical pregnancy rate (RR 1.00, 95% CI 0.86 to 1.16, 12 RCTs, n = 1998, I2 = 3%, moderate-quality evidence). This means that for a typical clinic with 23% LBR using a GnRH agonist regimen, switching to CC or Ltz protocols would be expected to result in LBRs between 15% and 30%. Clomiphene citrate or Ltz protocols were associated with a reduction in the incidence of OHSS (Peto OR 0.21, 95% CI 0.11 to 0.41, 5 RCTs, n = 1067, I2 = 0%, low-quality evidence). This means that for a typical clinic with 6% prevalence of OHSS associated with a GnRH regimen, switching to CC or Ltz protocols would be expected to reduce the incidence to between 0.5% and 2.5%. We found evidence of an increase in cycle cancellation rate with the CC protocol compared to gonadotropins in GnRH protocols (RR 1.87, 95% CI 1.43 to 2.45, 9 RCTs, n = 1784, I2 = 61%, low-quality evidence). There was moderate quality evidence of a decrease in the mean number of ampoules used,) and mean number of oocytes collected with CC with or without gonadotropins compared to the gonadotropins in GnRH agonist protocols, though data were too heterogeneous to pool.Similarly, in the poor-responder population, it is unclear whether there was any difference in rates of live birth (RR 1.16, 95% CI 0.49 to 2.79, 2 RCTs, n = 357, I2 = 38%, low-quality evidence) or clinical pregnancy (RR 0.85, 95% CI 0.64 to 1.12, 8 RCTs, n = 1462, I2 = 0%, low-quality evidence) following CC or Ltz with or without gonadotropin versus gonadotropin and GnRH protocol. This means that for a typical clinic with a 5% LBR in the poor responders using a GnRH protocol, switching to CC or Ltz protocols would be expected to yield LBRs between 2% to 14%. There was low quality evidence that the CC or Ltz protocols were associated with an increase in the cycle cancellation rate (RR 1.46, 95% CI 1.18 to 1.81, 10 RCTs, n = 1601, I2 = 64%) and moderate quality evidence of a decrease in the mean number of gonadotropin ampoules used and the mean number of oocytes collected, though data were too heterogeneous to pool. The adverse effects of these protocols were poorly reported. In addition, data on foetal abnormalities following use of CC or Ltz protocols are lacking.

AUTHORS' CONCLUSIONS

We found no conclusive evidence indicating that clomiphene citrate or letrozole with or without gonadotropins differed from gonadotropins in GnRH agonist or antagonist protocols with respect to their effects on live-birth or pregnancy rates, either in the general population of women undergoing IVF treatment or in women who were poor responders. Use of clomiphene or letrozole led to a reduction in the amount of gonadotropins required and the incidence of OHSS. However, use of clomiphene citrate or letrozole may be associated with a significant increase in the incidence of cycle cancellations, as well as reductions in the mean number of oocytes retrieved in both the general IVF population and the poor responders. Larger, high-quality randomized trials are needed to reach a firm conclusion before they are adopted into routine clinical practice.

Clomiphene citrate and letrozole to reduce follicle-stimulating hormone consumption during ovarian stimulation: systematic review and meta-analysis

OBJECTIVE

To assess the available evidence comparing effectiveness of ovarian stimulation (OS) using clomiphene citrate (CC) and/or letrozole (LTZ) to reduce follicle-stimulating hormone (FSH) consumption compared with standard OS.

METHODS

We performed a systematic review and meta-analysis of randomized controlled trials that compared reproductive outcomes following in-vitro fertilization. We searched 11 electronic databases and hand-searched the reference lists of included studies and related reviews. We stratified the results, separating studies according to the oral agent used (CC or LTZ) and the characteristics of the included women (expected poor ovarian response or other women). When combining the results of the included studies, we assessed the relative risk (RR) for live birth, clinical pregnancy, miscarriage and cycle cancelation, the Peto odds ratio (OR) for ovarian hyperstimulation syndrome (OHSS) and mean difference (MD) for the number of oocytes retrieved and FSH consumption.

RESULTS

A total of 22 studies were included in the review. Considering women with expected poor ovarian response, the available evidence suggested that using CC to reduce FSH consumption during OS provided similar rates of live birth (RR, 0.9 (95% CI, 0.6-1.2), moderate-quality evidence) and clinical pregnancy (RR, 1.0 (95% CI, 0.8-1.4), moderate-quality evidence); the use of LTZ did not cause a relevant change in the number of oocytes retrieved (MD, -0.4 (95% CI, -0.9 to 0.1), high-quality evidence). Considering the studies evaluating other women, the available evidence suggested that using CC to reduce FSH consumption during OS reduced the number of oocytes retrieved (MD, -4.6 (95% CI, -6.1 to -3.0), high-quality evidence) and risk of OHSS (Peto OR, 0.2 (95% CI, 0.1-0.3), moderate-quality evidence), while results were similar for rates of live birth (RR, 0.9 (95% CI, 0.7-1.1), moderate-quality evidence) and clinical pregnancy (RR, 1.0 (95% CI, 0.8-1.1), high-quality evidence). The quality of the evidence was low or very low for other outcomes.

CONCLUSION

The use of CC to reduce FSH consumption in women with expected poor ovarian response has the advantage of providing similar reproductive outcomes with reduced costs. For the other women, the use of CC for reducing FSH consumption has the additional advantage of reducing OHSS, but also reduces the total number of oocytes retrieved. More studies are needed to evaluate the effect of LTZ for the same purpose. Future studies should focus on cumulative pregnancy per oocyte retrieval, patient dissatisfaction and agreement to repeat the cycle if not pregnant, which are important outcomes for clinical decisions. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Reassessing the feasibility of the zygote score for predicting embryo viability in IVF/ICSI using the GnRH antagonist protocol compared to the long protocol

BACKGROUND

Many factors from the oocyte/sperm or the process of fertilization may affect the zygote formation. The zygote score (Z-score) describes the quality of a human zygote based on its pronuclear morphology, nucleolar precursor bodies, and alignment of polar bodies, and it can be used in the selection process at the zygote stage for embryo transfer or cryopreservation.

OBJECTIVE

The aim of this retrospective cohort study was to investigate the relationship between different controlled ovarian stimulation (COS) protocols and the zygote score (Z-score) and to assess the feasibility of the Z-score for predicting embryo survival in the GnRH-antagonist (GnRH-ant) protocol.

METHODS

It is a retrospective, single-center cohort study. A total of 3,826 zygotes with normal fertilization were analyzed from 744 in vitro fertilization /intra-cytoplasmic sperm injection (IVF/ICSI) cycles (long protocol n = 392; GnRH-ant n = 352) between Jan 2010 and April 2014 in the IVF unit of Chang-Gung Memorial Hospital Kaohsiung Medical Center.

RESULTS

The Z-score distribution differed significantly between these two protocols. The overall Z-score was poorer for zygotes from GnRH-ant cycles (p<0.05). Univariate and multivariate analyses indicated the type of COS protocol is one of the main determinants of Z-score grading. Our study found good-quality day 3 embryo/blastocyst formation and the cumulative embryo survival rate were correlated with the Z-score but not the COS protocol. With the GnRH-ant protocol, the number of Z1 in the transferred cohort embryos was significantly correlated with the clinical pregnancy rate (r = 0.976; p = 0.024) and live birth rate (r = 0.971; p = 0.029). This correlation was not seen with the long protocol.

CONCLUSIONS

The Z-score distribution for the GnRH antagonist cycles was poorer than that of the long protocol, but the Z-score system is a valuable parameter for predicting embryo viability in the GnRH-ant protocol, providing a strong correlation with the clinical pregnancy rate and live birth rate.

The state of "freeze-for-all" in human ARTs

The recent development of vitrification technologies and the good outcomes obtained in assisted reproduction technologies have supported new indications for freezing and segmentation of treatment. Beyond OHSS prevention and avoidance of embryo transfers in the setting of an adverse endocrinological profile or endometrial cavity, we have witnessed a trend to shift fresh embryo transfers to frozen embryo transfers in many programs. We critically review the available evidence and suggest that freeze-all is not "for all," but should be individualized.

What should be the protocol selection after failure of in-vitro fertilization at normoresponder patients: Agonist or antagonist?

Objective:

Evaluation of the impact of agonist or antagonist protocol selection on pregnancy outcomes after failure of in-vitro fertilization (IVF) treatment cycles which were down regulated with Gonadotropin Releasing Hormone (GnRH) agonist.

Materials and Methods:

This was a retrospective study. Two hundred and sixty nine patients who were treated with GnRH agonist protocol between years 2002-2012 at an IVF unit and underwent a second attempt following one year period after failure of IVF enrolled in the study. Age, basal FSH levels, antral follicle counts, duration of induction, the number of yielded oocytes, the number of transferred embryos and the transfer days, clinical and ongoing pregnancy rates were evaluated for each treatment cycle.

Results:

Normoresponder patients were separated into two groups according to the agonist or antagonist protocol selection at the second attempt and the results of two consequent IVF cycles were compared. There were no statistically significant difference between the groups for the dosage of administered gonadotropin, duration of induction, the count of yielded oocytes, the day and the number of transferred embryos (p>0.05). Furthermore the fertilization rate, clinical and ongoing pregnancy rates were similar in two groups.

Conclusion:

The selection of antagonist treatment is effective as agonist protocols at normoresponder patients after failure of IVF.

The impact of the embryo quality on the risk of multiple pregnancies

The aim of the present study was to determine the chance of pregnancy and the risk of multiple pregnancies taking into account the number and quality of transferred embryos in patients >36 years old or ≤36 years old. For this study, 1497 patients undergoing intra-cytoplasmic sperm injection (ICSI) cycles in a private assisted reproduction centre were split into groups according to the number and quality of the transferred embryos on the third or fifth day of development. The pregnancy rate and multiple pregnancy rate were compared between the embryo quality groups in patients <36 years old or ≥36 years old. In patients <36 years old, for the day 3 embryo transfer, no significant difference was noted in the pregnancy rate when the groups were compared. However the multiple pregnancy rate was increased by the transfer of an extra low-quality embryo (17.1 versus 28.2%, P = 0.020). For day 5 embryo transfer, the transfer of an extra blastocyst significantly increased the pregnancy rate (36.0 versus 42.4%, P < 0.001) and the multiple pregnancy rate (4.4 versus 16.9%, P < 0.001). In older patients, no significant difference was noted in the pregnancy rate when the groups were compared. However, when an extra low-quality embryo was transferred, a significantly increased rate of multiple pregnancies was observed for day 3 (18.2 versus 26.4%, P = 0.049) and day 5 embryo transfers (5.2 versus 16.1%, P < 0.001). In conclusion, the transfer of an extra low-quality embryo may increase the risk of a multiple pregnancy. In younger patients, the transfer of an extra low-quality blastocyst may also increase the chance of pregnancy.

Low dose of rFSH [100 IU] in controlled ovarian hyperstimulation response: a pilot study

Background

The initial dose of recombinant Follicle Stimulating Hormone [rFSH] to be used in assisted reproduction treatment depends on several factors, mainly the cause of the infertility and the patient’s age. For young patients [≤35 years] usually an initial dose of around 150 IU of rFSH is recommended, but there are no studies proving that this should actually be the standard initial dose. We aimed to report the experience of a low-cost Human Reproduction Center where a dose of 100 IU of rFSH was used for controlled ovarian hyperstimulation [COH].

Findings

An observational prospective study was performed on 212 women aged ≤38 years old that underwent high-complexity assisted reproduction treatments. The patients’ infertility was mainly caused by tuboperitoneal, idiopathic or male factors. Controlled ovarian stimulation was performed using 100 IU of rFSH. Regarding the COH, 53.8% of the patients presented a satisfactory response, 25.9% low response, 14.2% hyper-response, and 6.1% developed ovarian hyperstimulation syndrome. Of the 55 patients with poor response, 20 started a new cycle with an initial dose of 200 IU of rFSH; 65% showed a satisfactory response, 10% a poor response, 20% a hyper-response, and 5% developed OHSS.

Conclusion

The initial dose of 100 IU of rFSH was considered adequate for controlled ovarian hyperstimulation, meeting the aim to reduce the costs of the assisted reproduction treatment.

Comparison of results of cycles treated with modified mild protocol and short protocol for ovarian stimulation

The ovarian stimulation has been applied in order to increase the number of oocytes to compensate for the poor results of in vitro fertilization, allowing the selection of one or more embryos to be transferred. Our aim is to compare the results obtained in IVF/ICSI cycles using the short protocol for controlled ovarian stimulation to the results from the modified mild protocol used in our department. A total of 240 cycles were conducted from January 2010 to December 2011. When comparing both protocols, it could be observed that there was a significant difference in the quantity of gonadotropins doses in the mild protocol and in the short protocol. No significant difference was observed regarding pregnancy rates per cycle, 22% and 26.2%, in short and mild protocols, respectively. The protocols of controlled ovarian stimulation are often associated with high risk of complications such as ovarian hyperstimulation syndrome, excessive emotional stress, high rates of treatment dropouts, and abdominal discomfort. With the data obtained in this study, one can conclude that there are less risks and complications for the patient when using the mild stimulation protocol. It was also observed that in this group there was a slightly higher rate.

GnRH antagonists: do they open new pathways to safer treatment in assisted reproductive techniques?

GnRH antagonists (GnRHnt) induce a rapid decrease in LH and FSH, preventing and interrupting LH surges. Their properties do not require a desensitization period and allow their use in the late follicular phase. GnRHnt could replace GnRH agonists (GnRHa) in ovarian stimulation without their side-effects and their long period of desensitivity. Both protocols using GnRHnt were associated with a smaller amount of gonadotrophin, a shorter stimulation period and a lower incidence of ovarian hyperstimulation syndrome (OHSS) with statistically comparable pregnancy rates. There is room for improvement of both protocols concerning the programming, the antagonist dose and the timing of antagonist administration. Luteal support should be maintained until the results of further studies. The perinatal outcome appears to be similar to that of other stimulation regimens. Triggering of ovulation can be facilitated by GnRHa for patients at risk of OHSS. Provided that pregnancy rates equivalent to those obtained with GnRHa are confirmed in larger series, GnRHnt will clearly represent a safer alternative to GnRHa protocols in IVF.

Clomiphene citrate in combination with gonadotropins for controlled ovarian stimulation in women undergoing in vitro fertilization

BACKGROUND

Gonadotropins are the most commonly used medication for controlled ovarian stimulation in in vitro fertilization (IVF). However, they are expensive, invasive and are associated with risk of ovarian hyperstimulation syndrome (OHSS). With recent calls for patient friendly IVF, there has been an interest in the use of clomiphene citrate with or without gonadotropins to reduce the burden of injections. However, it is not known whether regimens using clomiphene are at least as effective as gonadotropins alone.

OBJECTIVES

To determine whether clomiphene citrate with gonadotropins (with or without mid-cycle antagonist) is more effective than gonadotropins with gonadotropin-releasing hormone (GnRH) agonists for controlled ovarian stimulation in IVF or intracytoplasmic sperm injection (ICSI) treatment.

SEARCH METHODS

Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched March 2012), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, first quarter), MEDLINE (1970 to March 2012), EMBASE (1985 to Mar 2012) and reference lists of articles. Relevant conference proceedings were handsearched.

SELECTION CRITERIA

Randomised controlled trials (RCT) were included. Live birth rate (LBR) per woman was the primary outcome.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility and quality of trials

MAIN RESULTS

Fourteen studies were included in the review. Meta-analysis could be performed with the data of 12 included studies, with a total of 2536 participants. There was no evidence that clomiphene along with gonadotropins for IVF, with or without mid-cycle GnRH antagonist, differed from gonadotropins alone in GnRH agonist protocols in terms of live births (5 RCTs, 1079 women; OR 0.93, 95% CI 0.69 to1.24) or clinical pregnancy (11 RCTs, 1864 women; OR 1.07, 95% CI 0.85 to1.33). This means that for a typical clinic with 23% LBR using a GnRH agonist regimen, switching to clomiphene protocols would be expected to result in LBRs between 16% and 26%. There was a significant reduction in the incidence of OHSS (5 RCTs, 1559 women; OR 0.23, 95% CI 0.10 to 0.52). This means that for a typical clinic with 3.5% prevalence of OHSS using a GnRH agonist regimen, switching to clomiphene citrate protocols would be expected to reduce the incidence to between 0.8% and 1.8%. The trials included in this review were very old and outcomes such as live births, multiple pregnancy, OHSS and miscarriages have not been reported by most studies.

AUTHORS' CONCLUSIONS

There was no evidence to indicate that clomiphene with gonadotropins (with or without GnRH antagonist) differed significantly from gonadotropins in GnRH agonist protocols for women undergoing IVF treatment, in terms of live births or pregnancy rates. Meanwhile, use of clomiphene led to a reduction in the incidence of OHSS. However, these results were based on data from a small number of underpowered randomised trials with few participants. Hence there was insufficient evidence to recommend use of clomiphene citrate in routine IVF practice. Larger trials with adequate power are required.

GnRH agonist versus GnRH antagonist in in vitro fertilization and embryo transfer (IVF/ET)

Several protocols are actually available for in Vitro Fertilization and Embryo Transfer. The review summarizes the main differences and the clinic characteristics of the protocols in use with GnRH agonists and GnRH antagonists by emphasizing the major outcomes and hormonal changes associated with each protocol. The majority of randomized clinical trials clearly shows that in "in Vitro" Fertilization and Embryo Transfer, the combination of exogenous Gonadotropin plus a Gonadotropin Releasing Hormone (GnRH) agonist, which is able to suppress pituitary FSH and LH secretion, is associated with increased pregnancy rate as compared with the use of gonadotropins without a GnRH agonist. Protocols with GnRH antagonists are effective in preventing a premature rise of LH and induce a shorter and more cost-effective ovarian stimulation compared to the long agonist protocol. However, a different synchronization of follicular recruitment and growth occurs with GnRH agonists than with GnRH antagonists. Future developments have to be focused on timing of the administration of GnRH antagonists, by giving a great attention to new strategies of stimulation in patients in which radio-chemotherapy cycles are needed.

How many eggs are needed to produce an assisted reproductive technology baby: is more always better?

OBJECTIVE

To evaluate the association between the number of mature (metaphase II [MII]) oocytes per assisted reproductive technology (ART) cycle and the likelihood of live birth.

DESIGN

Retrospective study.

SETTING

Academic infertility practice.

PATIENT(S)

Seven hundred thirty-seven infertile women undergoing their initial fresh embryo, nondonor IVF or intracytoplasmic sperm injection cycle at Montefiore's Institute for Reproductive Medicine and Health between January 2002 and December 2008.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Live birth.

RESULT(S)

Two hundred twenty-four cycles resulted in a live birth (30.4%). Live birth cycles had significantly more MII oocytes obtained per cycle as compared with their unsuccessful counterparts (11.0 ± 5.9 vs. 9.7 ± 6.2, respectively). Multivariate logistic regression was done to determine the minimum number of MII oocytes per cycle as a predictor of live birth after adjustment for age and historical maximum FSH values. Cycles that included the average number of MII in this cohort were used as a reference group. For cycles with five or fewer MII oocytes obtained, there was a statistically significant decrease in the likelihood of a live birth as compared with the reference group (odds ratio 0.61, 95% confidence interval 0.38-0.99). However, cycles with six or fewer obtained MII oocytes were not less likely to result in a live birth when compared with the reference group (odds ratio 0.69, 95% confidence interval 0.45-1.08).

CONCLUSION(S)

In our cohort, there was an advantage to obtaining six or more MII oocytes during the fresh oocyte retrieval compared with five or fewer oocytes. There was not an advantage, however, to obtaining 10 or more or 15 or more oocytes as compared with obtaining 6-9 oocytes. The strategy of aiming for a greater number of oocytes in an ART cycle should be revisited.

High-response intrauterine insemination cycles converted to low-cost in vitro fertilization

Background:

There is a trend to cancel intrauterine insemination (IUI) in women with a high response. The aim of this study was to evaluate the efficacy of low-cost in vitro fertilization (IVF) in high-response IUI cycles in comparison with conventional IVF.

Methods and materials:

A total of 46 women were included in the study. Group A (study group) included 23 women with hyper-response to IUI cycles who were converted to IVF. They received oral letrozole 2.5 mg twice daily from days 3–7 of the menstrual cycle, along with 75 International Units (IU) of recombinant follicle-stimulating hormone on days 3 and 8. Group B (control group) underwent conventional IVF, and received downregulation with a gonadotrophin-releasing hormone agonist followed by stimulation with recombinant follicle-stimulating hormone 150–300 IU/day. Ovulation was triggered by 10,000 IU of human chorionic gonadotrophin, followed by IVF and embryo transfer. The primary outcome measure analyzed was pregnancy rates in both groups.

Results:

The study group received a significantly lower (P = 0.001) total dose of follicle-stimulating hormone and had significantly (P = 0.002) decreased levels of terminal estradiol. Although the pregnancy rate (30.43% in the study group versus 39.13% in the conventional group) per stimulated cycle was higher in the conventional IVF group, the miscarriage rate (study group 4.34% versus conventional group 13.04%) was also higher, and hence the take-home baby rate (study group 26.08% versus conventional group 30.43%) was more or less similar in both the groups.

Conclusion:

IVF can be offered to women having a high response to IUI cycles with good pregnancy rates and at low cost compared with use of a conventional protocol, and therefore can be considered more patient-friendly in selected cases.

The redesigned follitropin α pen injector for infertility treatment

INTRODUCTION

Treatment for infertility may require multiple drugs and complex dosing schedules. Available injection devices for patients who require regular injections during treatment are reviewed in this article, focusing on pen injectors used to self-administer recombinant human follicle-stimulating hormone (follitropin α). Following the introduction of the first and second follitropin α pen injectors in the last decade, a third pen injector with improved design for the administration of follitropin α has been developed for use in fertility treatment cycles.

AREAS COVERED

This paper presents the results of the dose accuracy testing with this pen injector that was performed in accordance with international standards (EN ISO 11608-1:2000). This overview also provides an understanding of the key features of the redesigned pen injector that are of interest to healthcare professionals.

EXPERT OPINION

The availability of an improved injection device for the delivery of follitropin α used during infertility treatment cycles of ovulation induction and assisted reproductive technology offers patients and healthcare professionals new treatment administration options. As fertility treatment cycles involve the use of several injectable gonadotropins, a standard device that could be used for all such treatments would simplify both the administration and the teaching of administration considerably.

Heterosexual couples’ uses and meanings of ovarian stimulation: Relatedness, embodiment and emotions

This article is about how ovarian stimulation is understood within the context of heterosexual couples’ relationships. The empirical research involves 15 semi-structured interviews with patients in Portugal who have undergone IVF programmes performed with eggs collected in stimulated cycles. We argue that the uses and meanings of ovarian stimulation expressed in the patients’ narratives represent situated values and knowledges conveyed by existing emotional resources within multiple gendered relations and identities. We discuss how empirical reconfigurations work in a mode of conversion of physical and emotional pain so that the application of subcutaneous injections to women’s bodies makes sense within IVF couples’ daily routine and in their conjugal relationship. The different practices of men’s involvement in the injection of hormones into women’s bodies are perceived as emotional moments, and men’s cooperation and/ or protection seems to be essential in this domain. The cultural assumptions underlying women’s duties regarding maternity reinforce a moral framework in which the pain and the complications associated with the ovarian stimulation are naturalized, normalized and accepted.

Patient evaluation of the use of follitropin alfa in a prefilled ready-to-use injection pen in assisted reproductive technology: an observational study

BACKGROUND

Self-administration of recombinant human follicle-stimulating hormone (r-hFSH) can be performed using injection pen devices by women undergoing assisted reproductive technology procedures. The objective of this study was to explore the use of the prefilled follitropin alfa pen in routine assisted reproductive technology procedures in Germany.

METHODS

This prospective, observational study was conducted across 43 German IVF centres over a period of 1.75 years. Patients who had used the prefilled follitropin alfa pen in the current or a previous cycle of controlled ovarian stimulation completed a questionnaire to assess their opinions of the device.

RESULTS

A total of 5328 patients were included in the study. Of these, 2888 reported that they had previous experience of daily FSH injections. Significantly more patients reported that less training was required to use the prefilled follitropin alfa pen than a syringe and lyophilized powder (1997/3081 [64.8%]; p < 0.001 'less' versus 'more' training). Significantly more patients rated the prefilled follitropin alfa pen as easier in terms of use (2321/3206, 72.4%; p < 0.001 'much more easy' versus 'less easy') and daily injection (2384/3262, 73.1%; p < 0.001 'much more easy' versus 'less easy') than existing injection methods. Approximately one third of respondents rated the prefilled follitropin alfa pen as easier to use than the follitropin beta pen with reloadable cartridges. The majority (3378/4024, 83.9%) of patients had a general preference for the prefilled follitropin alfa pen over other injection methods.

CONCLUSIONS

In this questionnaire-based survey, routine use of the prefilled follitropin alfa pen was well accepted and associated with favourable patient perceptions. Users of the pen found it easier to initially learn how to use, and subsequently use, than other injection methods. In general, the prefilled follitropin alfa pen was the preferred method for self-administration of gonadotrophins. Together with previous findings, the results here indicate a high level of patient satisfaction among users of the prefilled follitropin alfa pen for daily self-administration of r-hFSH.

Attitudes towards single embryo transfer, twin and higher order pregnancies in patients undergoing infertility treatment: a review

The problems associated with twin and higher order pregnancies have assumed major importance, with international debate about multiple pregnancy; the single biggest risk with in vitro fertilisation (IVF). We have critically reviewed published papers on female patients' and their partners' views of single embryo transfer (SET) and twin or higher level pregnancies to identify the requirements needed to improve the acceptability of SET. Twenty relevant papers were identified and included in the review. Although the majority of IVF patients and their partners, in the more recent studies, exhibited a desire for twins rather than singletons, closer examination of the evidence revealed that elective SET (eSET) could become increasingly acceptable. As success rates of IVF have improved and the risks and consequences of multiple pregnancies are well-documented, patients have accepted the transfer of two rather than three embryos as standard practice. However, more would accept eSET if success rates approached those of double embryo transfer (DET). This emphasises the importance of improving success rates of eSET so that more patients can achieve a singleton birth with one IVF cycle. If patients were offered only SET, it is likely that this would be acceptable as the normal expectation of pregnancy is one baby. Measures to improve the acceptability of SET include: using eSET, especially with younger patients; including partners when providing risk information; improving eSET success rates; improving outcomes with cryopreserved embryos; changing reimbursement/free cycles to favour eSET; using legal enforcement.

Women's views on Friendly IVF: a qualitative preliminary study

OBJECTIVE

To study in the French Context women's experiences with a low-stimulation regimen of in vitro fertilisation (Friendly IVF) and to compare them with those of women undergoing standard IVF (S-IVF).

POPULATION AND METHODS

Two assisted reproduction technology centers participated in this preliminary study. Patients'views were explored qualitatively. In-depth interviews were conducted at the end of the second monitored cycle. Twelve friendly IVF patients and 13 S-IVF patients participated in the study.

RESULTS

The respondents indicated that the most positive aspect of Friendly IVF was the low doses of hormones used. Cancellation of cycles and failure of oocyte retrieval were perceived the most negatively. Women in the Friendly IVF group reported fewer side effects and expressed emotional distress less acutely than women in the S-IVF group. The Friendly IVF treatment was percieved as a first step, sustaining the hope of success with a standard treatment.

CONCLUSION

Friendly IVF, as practiced in the center studied, represents a valuable alternative for most respondents as a first step in IVF treatment.

Mild ovarian stimulation for IVF

BACKGROUND

Mild ovarian stimulation for in vitro fertilization (IVF) aims to achieve cost-effective, patient-friendly regimens which optimize the balance between outcomes and risks of treatment.

METHODS

Pubmed and Medline were searched up to end of January 2008 for papers on ovarian stimulation protocols for IVF. Additionally, references to related studies were selected wherever possible.

RESULTS

Studies show that mild interference with the decrease in follicle-stimulating hormone levels in the mid-follicular phase was sufficient to override the selection of a single dominant follicle. Gonadotrophin-releasing hormone antagonists compared with agonists reduce length and dosage of gonadotrophin treatment without a significant reduction in the probability of live birth (OR 0.86, 95% CI 0.72-1.02). Mild ovarian stimulation may be achieved with limited gonadotrophins or with alternatives such as anti-estrogens or aromatase inhibitors. Another option is luteinizing hormone or human chorionic gonadotrophin administration during the late follicular phase. Studies regarding these approaches are discussed individually; small sample size of single studies along with heterogeneity in patient inclusion criteria as well as outcomes analysed does not allow a meta-analysis to be performed. Additionally, the implications of mild ovarian stimulation for embryo quality, endometrial receptivity, cost and the psychological impact of IVF treatment are discussed.

CONCLUSIONS

Evidence in favour of mild ovarian stimulation for IVF is accumulating in recent literature. However, further, sufficiently powered prospective studies applying novel mild treatment regimens are required and structured reporting of the incidence and severity of complications, the number of treatment days, medication used, cost, patient discomfort and number of patient drop-outs in studies on IVF is encouraged.

[Premature ovarian failure: which protocols?]

This review shows the results of the various studies concerning the protocols applied to the women presenting a premature ovarian failure. Will be thus analyzed the natural cycles (or semi-natural), the increase in the dose of gonadotrophins, the clomiphene citrate and the anti-aromatases, the protocols with GnRH agonists long, short, stop or microdoses, the protocols with GnRH antagonists and the adjuvant treatments: aspirin, nitric oxyde, recombinant LH recombining, growth hormone and androgens. The interest of several protocols is to collect a sufficient number of oocytes (and thus of embryos to be transferred), making it possible to obtain reasonable rates of pregnancy. However, it arises that the rates of pregnancy observed among these women depend not only on their ovarian reserve and their age, but are also function of the type of infertility, of the cycle number and the uterus.

Pregnancy after in vitro fertilization-intracytoplasmic sperm injection obtained with a modified natural cycle in a BRCA1 mutation carrier

OBJECTIVE

To report a successful pregnancy after a semi-natural IVF cycle for a BRCA1 gene mutation carrier.

DESIGN

Case report.

SETTING

University hospital.

PATIENT(S)

A 26-year-old patient with BRCA1 gene mutation.

INTERVENTION(S)

Semi-natural IVF cycle and intracytoplasmic sperm injection.

MAIN OUTCOME MEASURE(S)

Pregnancy rate.

RESULT(S)

A modified natural IVF cycle was performed, resulting in pregnancy and delivery.

CONCLUSION(S)

A modified natural IVF cycle is an effective and safe solution for BRCA1 or BRCA2 mutation gene carrier women with couple infertility.

Different ovarian stimulation protocols for women with diminished ovarian reserve

PURPOSE

To review the available treatments for women with significantly diminished ovarian reserve and assess the efficacy of different ovarian stimulation protocols.

METHODS

Literature research performed among studies that have been published in the Pubmed, in the Scopus Search Machine and in Cohrane database of systematic reviews.

RESULTS

A lack of clear, uniform definition of the poor responders and a lack of large-scale randomized studies make data interpretation very difficult for precise conclusions. Optimistic data have been presented by the use of high doses of gonadotropins, flare up Gn RH-a protocol (standard or microdose), stop protocols, luteal onset of Gn RH-a and the short protocol. Natural cycle or a modified natural cycle seems to be an appropriate strategy. Low dose hCG in the first days of ovarian stimulation has promising results. Molecular biology tools (mutations, single nucleotide polymorphisms (SNPs)) have been also considered to assist the management of this group of patients.

CONCLUSIONS

The ideal stimulation for these patients with diminished ovarian reserve remains a great challenge for the clinician, within the limits of our pharmaceutical quiver.

Natural cycle IVF: a question of semantics?

Recently there has been much discussion and presentation on IVF protocols using less stimulation or indeed none at all. Our experience with controlled natural cycle IVF over the last few years has convinced us that this is a powerful tool for many patients in the treatment of infertility. The protocol we employ has raised some questions as to whether it is natural cycle or stimulated cycle. We have reported a large series of cycles and seen no stimulatory effects of the medications used to control the cycle, thereby confirming our position that controlled natural cycle IVF is a valid option as an assisted reproduction treatment.

Effets de la stimulation sur la qualité ovocytaire

In all IVF programs, ovarian stimulation may lead to a hyperstimulation syndrome. Mild ovarian stimulations are suggested to reduce this complication of infertility treatment. In this article, we wonder what the consequences of different stimulations are on oocytes quality. The quality of the oocyte being the major factor of the development of a good embryo, it can be evaluated by direct or indirect techniques. Some are subjective. Several studies seem to show that ovarian stimulation has an influence on oocye quality, especially at a chromosomic and perharps, epigenetic level. It seems that a mild stimulation (for example with GnRH antagonist) selects less oocytes but with a better quality and produces euploid embryos. The uterine transfer of this kind of embryo should lead to an ongoing pregnancy.

Le cycle naturel en fécondation in vitro chez les mauvaises répondeuses

Since the beginning of IVF, natural cycle In Vitro Fertilization (NC-IVF) has been largely replaced by IVF with ovarian stimulation. However, natural cycle IVF has several advantages: low cost, no risk of ovarian hyper stimulation syndrome, very low risk of multiple pregnancy. Nevertheless, natural cycle IVF is less effective with a high risk of cancellation due to premature rise of LH, and an increased risk of failed oocyte retrieval. Using GnRH antagonists in a modified natural cycle decreases the occurrence of a premature LH rise. In the context of a poor responder patient, natural IVF could theoretically yield a better quality oocyte coming from a naturally selected follicle and allow a transfer on an endometrium whose receptivity has not been distorted by controlled ovarian stimulation. However, the real place for it has yet to be defined as we lack published data. Only one randomised controlled study in poor responders showed a similar pregnancy rate to a standard protocol representing a cost-effective alternative. Available retrospective data seem to show the same trend especially in the sub group of younger patients (below 38). Natural cycle IVF is a low-risk, low-cost procedure whose interesting results should be further confirmed by large scale prospective studies.

In vitro fertilization and embryo transfer in seminatural cycles for patients with ovarian aging

OBJECTIVE

To investigate whether seminatural cycle is a reasonable management for ovarian aging patients.

DESIGN

Prospective study.

SETTING

ART Unit, Clamart, France.

PATIENT(S)

Seventy-five women, 158 cycles.

INTERVENTION(S)

Infertile women who presented with ovarian aging (defined as low ovarian reserve and characterized by cycle day 3 high FSH, high E2, and/or low inhibin B and/or previous cycle cancellations due to poor ovarian response to COH) were studied. Patients were offered up to three cycles. Treatment was scheduled as follows. From cycle day 8 onward the selection of the dominant follicle was monitored by ultrasound and hormonal measurements. When the dominant follicle appeared, patients received GnRH antagonist and, thereafter, hMG to support further follicular development.

MAIN OUTCOME MEASURE(S)

Implantation rate and clinical pregnancy.

RESULT(S)

Twenty-eight of 158 cycles were cancelled (17.7%). Oocyte pickups were performed in 119 (75.3%) cycles, 91 (57.6%) mature oocytes were retrieved, and 67 (42.4%) embryos transferred. Nineteen clinical pregnancies were obtained; the cumulative pregnancy rate per patient, after 3 cycles, was 35.2%.

CONCLUSION(S)

Use of a seminatural cycle is a reasonable management for patients with ovarian aging who have ovulatory menstrual cycles. It achieves a high implantation rate (28.3%).

Oocyte number per live birth in IVF: were Steptoe and Edwards less wasteful?

As part of a learning exercise to assess the efficiency of oocyte utilization after controlled ovarian stimulation, we compared historical data from the publications of Steptoe and Edwards describing their early experiences in Oldham and at Bourn Hall with retrospective data from IVF and ICSI cycles carried out at Bourn Hall Clinic during the year 2000. For the purpose of analysing the more recent data, patients were subdivided into groups by age (< or = 37 years and > or = 38 years) and by oocyte yield (low, intermediate and high). In patients less than 38 years of age, live birth rates were equivalent in each group, irrespective of the number of oocytes retrieved. Patients who yielded low numbers of oocytes (1-5) utilized an average of 9.6 oocytes per live birth, compared with 25.1 and 51.5 in those who yielded intermediate (6-16) and high (16+) numbers of oocytes. The comparison with historical data suggests that the 'efficiency' of oocyte utilization has not improved significantly since the early 1980s, despite 25 years' experience of controlled ovarian stimulation for IVF treatment.

Minimal stimulation IVF with late follicular phase administration of the GnRH antagonist cetrorelix and concomitant substitution with recombinant FSH: a pilot study

BACKGROUND

The use of the natural cycle for IVF offers the advantage of a patient-friendly and low-risk protocol. Its effectiveness is limited, but may be improved by using a GnRH antagonist to prevent untimely LH surges.

METHODS

In this pilot study, minimal stimulation IVF with late follicular phase administration of the GnRH antagonist cetrorelix and simultaneous substitution with recombinant FSH was applied for a maximum of three cycles per patient. Main outcome measures were pregnancy rates per started cycle and cumulative pregnancy rates after three cycles.

RESULTS

A total of 50 patients completed 119 cycles (2.4 per patient). Fifty-two embryo transfers resulted in 17 ongoing pregnancies [14.3% per started cycle; 32.7% per embryo transfer; 95% confidence interval (CI) 7.9-20.7% and 19.7-45.7%, respectively]. One dizygotic twin pregnancy occurred after transfer of two embryos, the other pregnancies were singletons. The cumulative ongoing pregnancy rate after three cycles was 34% (95% CI 20.6-47.4%). Live birth rate was 32% per patient (95% CI 18.8-45.2%).

CONCLUSIONS

Pregnancy rates after IVF with minimal, late follicular phase stimulation are encouraging. Considering the low-risk and patient-friendly nature of this protocol, it may be a feasible alternative to IVF with ovarian hyperstimulation.

Premature luteinization during gonadotropin-releasing hormone antagonist cycles and its relationship with in vitro fertilization outcome

OBJECTIVE

To determine the prevalence and the effect of premature luteinization in GnRH antagonist IVF-ET cycles.

DESIGN

Prospective observational study.

SETTING

In vitro fertilization-embryo transfer (IVF-ET) program at the Instituto Valenciano de Infertilidad.

PATIENT(S)

Eighty-one infertile patients undergoing controlled ovarian hyperstimulation with gonadotropins and GnRH antagonist for IVF-ET.

INTERVENTION(S)

Gonadotropin-releasing hormone (GnRH) antagonist was administered from stimulation day 6. Serum P, E(2), and LH were determined on the day of hCG administration.

MAIN OUTCOME MEASURE(S)

Cycles were grouped according to serum P level on the day of hCG administration (<1.2 ng/mL or > or =1.2 ng/mL). Clinical pregnancy and implantation rates were determined.

RESULT(S)

The incidence of premature luteinization was 38.3%. Total recombinant FSH dose and stimulation days differed significantly between the groups. Pregnancy rate (25.8% vs. 54.0%) and implantation rate (13.8% vs. 32.0%) were significantly lower in the premature luteinization group.

CONCLUSION(S)

Premature luteinization during GnRH antagonist IVF-ET cycles is a frequent event that is associated with lower pregnancy and implantation rates. Progesterone elevations are not related to serum LH levels and may reflect the mature granulosa cell response to high FSH exposure.

[Revisiting the clomifene-gonadotropin protocol in IVF with the use of a GnRH antagonist]

OBJECTIVE

To assess the ability of GnRH antagonists to prevent LH surges during superovulation for IVF in classical stimulation protocols with clomiphene and gonadotropins.

PATIENTS AND METHODS

Fifty-eight patients were treated with clomiphene (100 mg daily for 5 days starting on cycle day 2) and gonadotropins (225 UI HMG on cycle days 5, 7 and 9), with monitoring starting on cycle day 10. Cetrorelix, 0.25 mg, was administered daily when dominant follicle diameter reached 18 mm and/or plasma estradiol levels 800 pg/ml.

RESULTS

No premature LH surge was observed during the 48 stimulation cycles completed. The pregnancy rate was 20.8% per punction and 25.6% per transfer, and there was no clinical ovarian hyperstimulation syndrome in these series.

CONCLUSIONS

Cetrorelix, 0.25 mg, optimizes the classical stimulation with clomiphene and gonadotropins by preventing LH surges; the so-completed protocol yields acceptable pregnancy rates with lower hormone quantities and reduced risks of ovarian hyperstimulation, and becomes a convenient choice when "softer" treatments for IVF are considered.

Patient-friendly ovarian stimulation

The ultimate goal of successful IVF is the birth of a healthy child with no maternal complications. Advances in ovarian stimulation protocols using gonadotrophin-releasing hormone agonists (GnRHa) and high doses of gonadotrophins have resulted in increased oocyte numbers with improved pregnancy and birth rates. However, the efficacy of such therapy is controversial when measured against the potential side effects. These side effects include those arising from oestrogen deprivation during desensitization, complications associated with an increased risk of ovarian hyperstimulation syndrome (OHSS), and an increased possibility of multiple births. Additionally, the increased cost due to more frequent monitoring and increased drug dosage negatively impacts on patient care. Thus, refinements in drug regimens are needed not only to address these side effects, but also to target the quality, not the quantity, of oocytes. In studies comparing GnRH antagonist (GnRHnt) to GnRHa, patients receiving GnRHnt underwent a shorter induction using less gonadotrophin, the incidence of OHSS was reduced and they reported a better quality of life. While larger studies are needed to confirm these promising findings, it appears that milder stimulation protocols could represent an interesting option, at least for selected patients.

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.

Induction of follicular growth and ovulation with urinary and recombinant gonadotrophins

Gonadotrophins have been used since the 1930s. By the 1990s, a pure biological extract of FSH was obtained. The increase in the demand for new assisted reproduction techniques led to the creation of recombinant FSH, 99% pure and highly consistent between batches, with no LH activity, and a high specific activity. In gonadotrophin protocols, follicular growth can be monitored with regular ultrasounds and/or hormonal testing, mainly oestradiol in the follicular phase. In assisted reproduction the adoption of ovulation induction strategies with GnRH analogues, control the endogenous secretion of LH, avoiding cancellations due to an early LH surge, and premature ovulation. Depending on the moment when pituitary suppression starts, there are short, ultra-short and long protocols The use of long protocols not only increases pregnancies and live births, it also allows an easier programming and simplifies IVF treatments. Ovarian stimulation entails some risks such as ovarian hyperstimulation syndrome and multiple pregnancies that can be avoided in many cases with an accurate prediction and an active prevention.

The added value of embryo cryopreservation to cumulative ongoing pregnancy rates per IVF treatment: is cryopreservation worth the effort?

PURPOSE

To calculate the added benefit of a cryopreservation program to the cumulative ongoing pregnancy rate over a maximum of three cycles of IVF.

METHODS

A total of 1251 couples beginning their first IVF treatment between January 1995 and December 1999 were evaluated. Ongoing pregnancies from fresh and subsequent cryopreserved embryo transfer cycles were analyzed. Pregnancies arising from the cryopreservation cycle were considered to augment the cumulative pregnancy rate when no ongoing pregnancy arose from the fresh embryo transfer cycle.

RESULTS

The ongoing pregnancy rate per cryopreserved embryo transfer was 11.7%. The cumulative ongoing pregnancy rate following three successive started fresh IVF cycles was 42.5%. When pregnancies arising from the transfer of thawed cryopreserved embryos were included, the cumulative ongoing pregnancy rate increased to 43.8%, rising to 44.8% when extrapolated data from as yet unthawed embryos was included.

CONCLUSIONS

When analyzed in these terms, the supplementary benefit of cryopreserving supranumerical embryos appears limited.

Clinical outcome of treatment cycles using preimplantation genetic diagnosis for structural chromosomal abnormalities

OBJECTIVES

To explore oocyte recovery, embryo quality, the number of transferable embryos and pregnancy rate after preimplantation genetic diagnosis (PGD) in patients with structural chromosomal aberrations.

METHODS

PGD was performed in seven couples with Robertsonian translocations (Rob), eight couples with reciprocal translocations (Rec), two couples with inversions and one couple with a deletion. A total of 43 treatment cycles were carried out.

RESULTS

A total of 14.2 oocytes per cycle were retrieved. Fertilisation and cleavage rates were 63% and 58%, respectively. Of the biopsied embryos 20% were transferable. Comparison of the Rob and Rec group revealed no significant differences in number of oocytes, fertilisation or cleavage rates. The number of transferable embryos after biopsy was significantly higher in the Rob group than in the Rec group. When embryo transfer (ET) was performed the pregnancy rate did not differ between the Rob and the Rec groups. Twenty-eight embryo transfers (one or two embryos) were carried out leading to eight clinical pregnancies (29% per ET): two twins, four singletons, one miscarriage and one ectopic pregnancy. All the children are carriers of balanced chromosomal aberrations.

CONCLUSION

An acceptable pregnancy rate can be achieved among couples with structural chromosomal abnormalities.

A randomized study comparing IVF in the unstimulated cycle with IVF following clomiphene citrate

The efficiency of IVF in unstimulated cycles was compared with that following ovarian stimulation with clomiphene citrate in a simple protocol with ultrasound monitoring only. A total of 132 couples with no previous IVF attempts, selected by female age <35 years, indication for intracytoplasmic sperm injection or infertility caused by tubal factor or unexplained infertility were randomized to the two protocols. Randomization yielded two comparable groups. The clomiphene group (68 couples) performed significantly better than the unstimulated group (64 couples) in terms of number of cycles with oocyte harvest (90/111 or 81% versus 65/114 or 57%; chi(2) = 9.21, P < 0.002), embryo transfers per started cycle (59/111 or 53% versus 29/114 or 25%; chi(2) = 18.14, P < 0.0001), live intrauterine pregnancy rate per started cycle (20/111 or 18% versus 4/114 or 4%; chi(2) = 12.42, P < 0.0001), live intrauterine pregnancy rate per embryo transfer (20/59 or 34% versus 4/29 or 14%; chi(2) = 3.96, P = 0.047), but not in terms of implantation rate (22/85 or 26% versus 4/29 or 14%; chi(2) = 1.65). Only two twin pregnancies occurred. Modest side-effects were recorded following clomiphene. Accordingly, a simple clomiphene citrate protocol, but not IVF in unstimulated cycles, seems compatible with the concept of 'friendly IVF', yielding a fair pregnancy rate both per cycle started and per embryo transfer in selected patients. The results do not substantiate any important negative anti-oestrogenic effects of clomiphene.

New concepts in superovulation strategies for assisted conception treatments

Controlled ovarian stimulation for in-vitro fertilization treatment using preparations that contain follicle-stimulating hormone has been routinely performed since the 1980s. The early preparations were urinary human menopausal gonadotrophins, containing follicle-stimulating hormone and luteinizing hormone. In the early 1990s, highly purified follicle-stimulating hormone preparations were introduced because of a desire to provide drugs for subcutaneous administration with a lower risk of allergic reactions. Intensive research resulted in the discovery of recombinant follicle-stimulating hormone, which is more potent that the highly purified follicle-stimulating hormone, resulting in significantly higher clinical pregnancy rates. The two recombinant follicle-stimulating hormone preparations available appear to be equally effective and provide comparable results. Gonadotrophin-releasing hormone antagonists, which have recently been introduced, appear to be effective in preventing a premature rise in luteinizing hormone during ovarian stimulation for in-vitro fertilization, as well as improved response to lower doses of gonadotrophins. It is envisaged that the availability of recombinant gonadotrophins and gonadotrophin-releasing hormone antagonists will ultimately lead to shorter, cheaper and safer treatments, using reduced dosages.

A prospective, randomized clinical trial comparing 150 IU recombinant follicle stimulating hormone (Puregon((R))) and 225 IU highly purified urinary follicle stimulating hormone (Metrodin-HP((R))) in a fixed-dose regimen in women undergoing ovarian stimulation

A prospective, randomized, open, multicentre (n = 3) study was conducted to compare the efficacy and efficiency of a fixed daily dose of 150 IU (3x50 IU) recombinant follicle stimulating hormone (recFSH, Puregon((R))) and 225 IU (3x75 IU) highly purified urinary FSH (uFSH-HP, Metrodin-HP((R))) in women undergoing ovarian stimulation prior to in-vitro fertilization treatment. A total of 165 women were treated with FSH, 83 subjects with recFSH and 82 subjects with uFSH-HP. In the recFSH group a mean number of 8.8 oocytes were retrieved, compared with 9.8 in the uFSH-HP group (not statistically significant). In the recFSH group, a significantly lower total dose was required compared to the uFSH-HP group, 1479 versus 2139 IU, respectively (P < 0.0001; 95% confidence interval -747 to -572). Treatment with recFSH resulted in a significantly higher embryo development rate (69.6 versus 56.2%; P = 0.003) and more embryos accessible for the embryo freezing programme (3.3 versus 2.0; P = 0.02) compared to uFSH-HP. The vital pregnancy rate per cycle started was 30.2 versus 28.3% in the recombinant and urinary FSH group, respectively. It is concluded that treatment outcome of a fixed daily dose of 150 IU recFSH is comparable to a fixed daily dose of 225 IU uFSH-HP. However, a significantly lower total dose was needed in the recFSH group (nearly 700 IU less).

Effect of prednisolone on serum and follicular fluid androgen concentrations in women with polycystic ovary syndrome undergoing in-vitro fertilization

Increased androgen concentrations are thought to be detrimental to oocyte quality and reproductive potential. Adjuvant treatment with glucocorticoids has been tried to suppress androgens in women undergoing infertility treatment. In the present study 20 infertile women with polycystic ovary syndrome were prospectively randomized in a placebo-controlled study to receive either placebo or prednisolone 10 mg at night, during standard in-vitro fertilization (IVF) treatment. Serum samples for assays of gonadotrophins, steroids and sex hormone-binding globulin (SHBG) were collected before treatment, at down-regulation, and at oocyte retrieval. Up to five follicles in each ovary were analysed separately regarding follicular fluid and oocytes, the rest according to the clinic's routines. In the placebo group, serum dehydroepiandrosterone (DHEA) and dehydroepiandrosterone-sulphate (DHEA-S) did not change between down-regulation and oocyte retrieval, whereas adjuvant prednisolone resulted in a significant decrease. In follicular fluid, adjuvant prednisolone resulted in significantly lower concentrations of DHEA-S as compared to placebo, no other significant differences were found. No significant differences were found in embryo characteristics or pregnancy rates between the groups.