Serum oestradiol and progesterone concentrations during prolonged coasting in 15 women at risk of ovarian hyperstimulation syndrome following ovarian stimulation for assisted reproduction treatment

Serum Oestradiol Pattern during Coasting is Different in Antagonist Cycles Compared with Long Agonist Cycles in In Vitro Fertilisation

BACKGROUND

GnRH agonists and antagonists have different mechanism of action, and therefore serum estradiol levels might differ during coasting in IVF.

AIMS

To compare the change in serum oestradiol levels after withholding the gonadotropins for coasting between long agonist and antagonist cycles.

STUDY DESIGN

Retrospective study.

METHODS

Antagonist and long agonist cycles, in which coasting was performed, were analysed in this retrospective analysis. Antagonist cycles (n=50) were compared with long agonist cycles (n=52) with respect to daily serum oestradiol levels following withholding of gonadotropins.

RESULTS

The pattern of change in serum oestradiol was different between groups; it increased on the first day by 11.2% and decreased thereafter on the second and third days in the agonist group. However, it began to decrease from the first day in the antagonist group. Therefore, peak serum oestradiol levels were significantly higher in the agonist group than in the antagonist group (mean±standard deviation; 5798±1748 vs 5104±1351 pg/mL). The duration of coasting was shorter in the antagonist group compared with that in the agonist group (mean±standard deviation; 2.60±1.40 vs 1.96±0.88 days).

CONCLUSION

Serum oestradiol pattern during coasting is different in antagonist cycles compared with long agonist cycles in in vitro fertilisation.

Clinical and endocrine response to the withdrawal of gonadotropin-releasing hormone agonists during prolonged coasting

OBJECTIVE

To compare the clinical and endocrine response of cycles in which GnRH agonists (GnRH-a) were stopped with cycles in which the agonists were continued during coasting.

DESIGN

Retrospective study of stimulation cycles using flare and luteal agonist protocols.

SETTING

Academic.

PATIENT(S)

Fifty-nine IVF and intracytoplasmic sperm injection (ICSI) treatment cycles in 57 women, coasted for 3 or more days.

INTERVENTION(S)

The GnRH-a were withdrawn when E(2) levels continued to increase during coasting.

MAIN OUTCOME MEASURE(S)

Hormone concentrations, ultrasound findings, cycle cancellation, ovarian hyperstimulation syndrome (OHSS), oocyte retrieval, fertilization, embryo transfer, and clinical pregnancy rates (PR).

RESULT(S)

In the GnRH-a withdrawn group E(2) levels decreased by 63% (18,043-6,656 pmol/L) without cycle cancellations or cases of severe OHSS. In the agonist continuation group, the spontaneous E(2) decrease was 29% (14,205-10,132 pmol/L) with cycle cancellation and severe OHSS rates of 9.5% (4/42) and 4.8% (2/42), respectively. Oocyte retrieval, fertilization, embryo transfer, and clinical PRs were not compromised by stopping the agonists. Variations in the dynamic responses of FSH, LH, anti-Müllerian hormone, P, and androstenedione (A) levels in these cycles are described.

CONCLUSION(S)

Withdrawal of GnRH-a during coasting interrupted increasing E(2) levels, prevented cycle cancellation, and mitigated the risk of OHSS in this high risk group without compromising oocyte retrieval, fertilization, embryo transfer, or PRs.

Short coasting of 1 or 2 days by withholding both gonadotropins and gonadotropin-releasing hormone agonist prevents ovarian hyperstimulation syndrome without compromising the outcome

OBJECTIVE

To evaluate the effect of short coasting, by withdrawing both gonadotropins and gonadotropin-releasing hormone (GnRH) agonist, on the prevention of severe ovarian hyperstimulation syndrome (OHSS) without compromising pregnancy outcome.

DESIGN

Retrospective study.

SETTING

Large urban medical center.

PATIENT(S)

Forty-four women who had been coasted during controlled ovarian hyperstimulation (COH) for in vitro fertilization (IVF).

INTERVENTION(S)

When >or=20 follicles >15 mm with serum estradiol (E(2)) level of 4000 pg/mL were detected, both gonadotropins and GnRH agonist were withheld for 1 to 2 days.

MAIN OUTCOME MEASURE(S)

Changes of serum E(2) levels, number of oocytes retrieved, pregnancy rate.

RESULT(S)

The mean serum E(2) level fell from 7915 pg/mL at the onset of coasting to 3908 pg/mL on the day of human chorionic gonadotropin (hCG) administration. The mean number of oocytes retrieved and fertilization rate were 17.2% and 75.0%, respectively. Eighteen patients became pregnant (43.9%), and the implantation rate was 12.7%. Twenty-eight patients were coasted for 1 day, and 13 were coasted for 2 days. The mean decrease rate of serum E(2) level was 45.3% in 1-day coasting and 26.4% (first day) and 75.3% (second day) in 2-day coasting. The pregnancy outcome was similar between both groups. After coasting, three mild and two severe cases of OHSS occurred.

CONCLUSION(S)

Coasting for 1 or 2 days can be used successfully to prevent OHSS without compromising IVF cycle outcome.

Ganirelix acetate causes a rapid reduction in estradiol levels without adversely affecting oocyte maturation in women pretreated with leuprolide acetate who are at risk of ovarian hyperstimulation syndrome*

BACKGROUND

Elevated estradiol (E(2)) levels predispose to development of ovarian hyperstimulation syndrome (OHSS). Since GnRH antagonist is associated with a reduction in E(2) levels, we hypothesized that GnRH-antagonist treatment of women down-regulated with GnRH agonist who are at risk of OHSS might reduce E(2) levels and avoid cycle cancellation.

METHODS

Retrospective study in a university-based assisted reproduction technology (ART) programme in 87 patients treated with long luteal (LL) or microdose flare (MDF) with ovarian hyperresponse and 87 control patients without ovarian hyperresponse. GnRH-antagonist (ganirelix acetate) treatment was started and leuprolide acetate discontinued in women who failed to respond to a reduction in gonadotrophin dosage.

RESULTS

In the treatment group, there was a significant, reproducible reduction in serum E(2) levels. Mean E(2) at the start of ganirelix treatment was 4219.8 pg/ml and decreased in 24 h to 2613.7 pg/ml (36.7%; P < 0.001). An average of 24.9 +/- 8.8 oocytes were obtained at retrieval and an average of 19.1 +/- 8.0 were metaphase II (79.2%). Fertilization occurred in 13.9 +/- 8.1 embryos (72.8%). In this high risk group, two cases of severe OHSS (2.3%) occurred. The ongoing pregnancy rate was 51.8%. Compared with the control group, there were no statistically significant differences in the rate of oocyte recovery, oocyte maturity, 2PN rate, fertilization, cancellation, OHSS or pregnancy.

CONCLUSIONS

GnRH-antagonist treatment of women pretreated with GnRH agonist rapidly reduced circulating serum E(2) without adversely affecting oocyte maturation, fertilization rates or embryo quality and resulted in a high pregnancy rate in this subgroup of patients at risk of OHSS.

Interactions of the hormones leptin, ghrelin, adiponectin, resistin, and PYY3-36 with the reproductive system

OBJECTIVE

To summarize the effects of novel hormones (leptin, ghrelin, adiponectin, resistin, and PYY3-36) secreted from adipose tissue and the gastrointestinal tract that have been discovered to exert different effects on several reproductive functions, such as the hypothalamic-pituitary-gonadal axis, embryo development, implantation physiology, and clinically relevant conditions.

DESIGN

A MEDLINE computer search was performed to identify relevant articles.

RESULT(S)

Leptin and ghrelin exert important roles on body weight regulation, eating behavior, and reproduction, acting on the central nervous system and target reproductive organs. As a marker of adequate nutritional stores, these hormones may act on the central nervous system to initiate the complex process of puberty and maintain normal reproductive function. In addition, leptin and ghrelin and their receptors are involved in reproductive events such as gonadal function, embryo development, and embryo-endometrial interaction.

CONCLUSION(S)

Leptin and ghrelin and other adipose tissue-secreted hormones have significant effects on reproduction. Acting through the brain, these hormones may serve as links between adipose tissue and the reproductive system to supply and regulate energy needs for normal reproduction and pregnancy. Future studies are needed to further clarify the role of these hormones in reproductive events and other related gynecological conditions.

Treatment with gonadotropin-releasing hormone (GnRH) antagonists in women suppressed with GnRH agonist may avoid cycle cancellation in patients at risk for ovarian hyperstimulation syndrome

Forty-seven patients at high risk for ovarian hyperstimulation syndrome because of markedly elevated serum E2 levels on either long-luteal or microdose flare leuprolide acetate regimens were treated with ganirelix acetate. Despite being pretreated with GnRH agonist and without withholding gonadotropins, serum E2 decreased by 49.5% and 41.0% of pretreatment values (long luteal and microdose flare, respectively) after initiation of ganirelix, and 68.1% of the patients became pregnant.

Efficacy of low-dose human chorionic gonadotropin alone to complete controlled ovarian stimulation

OBJECTIVE

To prove that low-dose hCG alone can be clinically used to replace FSH-containing gonadotropins to complete controlled ovarian hyperstimulation (COH).

DESIGN

Controlled, prospective, randomized study.

SETTING

Academic center.

PATIENT(S)

Infertile patients who are candidates for assisted reproduction.

INTERVENTION(S)

Patients received [1] recombinant FSH or hMG throughout COH (group A); [2] ovarian priming with recombinant FSH/hMG followed by low-dose hCG (200 IU/day) alone (group B).

MAIN OUTCOME MEASURE(S)

Medication consumption; daily serum and follicular fluid (FF) measurements of LH, FSH, hCG, E2, P, T, and androstenedione (A); number and size of follicles; intracytoplasmic sperm injection (ICSI) outcome.

RESULT(S)

In group B: [1] duration and dose of recombinant FSH/hMG administration were reduced; [2] preovulatory serum hCG, E2, and T were higher, whereas FSH was lower; [3] FF hCG, E2, T levels, and E2/T, E2/A, and E2/P ratios were higher, whereas A was lower; [4] small but not large preovulatory follicles were reduced; [5] fertilization rates were higher; and [6] serum and FF P levels, and ICSI outcome did not differ.

CONCLUSION(S)

Low-dose hCG alone in the late COH stages: [1] reduced recombinant FSH/hMG consumption whereas ICSI outcome was comparable to traditional COH regimens; [2] stimulated follicle growth and maturation independent of FSH administration; [3] was associated with a reduced number of small preovulatory follicles; [4] did not cause premature luteinization; [5] resulted in a more estrogenic intrafollicular environment.

Falling estradiol levels as a result of intentional reduction in gonadotrophin dose are not associated with poor IVF outcomes, whereas spontaneously falling estradiol levels result in low clinical pregnancy rates

BACKGROUND

Although estradiol levels remain an integral part of monitoring in most IVF programmes, the effect of falling estradiol on IVF outcome has not been adequately quantified. The objective of this study was to evaluate the effect of falling estradiol levels prior to hCG on IVF outcome.

METHODS

This was a retrospective cohort study carried out in a university-based fertility clinic. A total of 112 IVF patients in whom estradiol levels fell prior to the administration of hCG were matched for age and year of treatment with 112 control IVF patients. IVF outcomes including oocytes retrieved, fertilization rate, embryos for transfer, and pregnancy rates were compared between the groups.

RESULTS

Seventy per cent of women in the falling estradiol group experienced spontaneously falling estradiol levels. Spontaneously falling estradiol was associated with fewer oocytes retrieved (median 5 versus 8, P=0.001), increased rates of failed fertilization (18 versus 6%, P=0.018) and lower clinical pregnancy rates (12 versus 26%, P=0.012) compared to controls. Despite marked decreases in estradiol levels, IVF outcomes for patients whose estradiol levels fell as a result of deliberate protocol modification had similar fertilization and clinical pregnancy rates as controls.

CONCLUSIONS

Subtle (<10%) spontaneous decreases in estradiol levels are associated with very poor IVF outcomes.

Serum leptin concentrations in patients with severe ovarian hyperstimulation syndrome during in vitro fertilization–embryo transfer treatment

OBJECTIVE

To investigate the changes in serum leptin concentration in the conception cycle of severe ovarian hyperstimulation syndrome (OHSS).

DESIGN

Prospective longitudinal study of 66 IVF-ET cycles between May 2000 and June 2002.

SETTING

Infertility outpatient clinic at a Japanese medical school.

PATIENT(S)

Infertile patients undergoing IVF-ET cycles at the infertility outpatient clinic were divided into three groups consisting of group 1 (conception-cycle patients with severe OHSS, n = 9), and group 2 (conception cycle, non-OHSS, n = 28), and group 3 (nonconception cycle, non-OHSS, n = 29).

INTERVENTION(S)

Blood samples were collected at five different periods. Period I, on the first day of ovarian stimulation with FSH; period II, at hCG administration before oocyte retrieval; period III, 7 days after oocyte retrieval; period IV, 14 days after oocyte retrieval; and period V, 21 days after oocyte retrieval.

MAIN OUTCOME MEASURE(S)

Serum leptin concentration.

RESULT(S)

The serum leptin concentration was low in the OHSS group compared with that of the non-OHSS groups in all serum samples, with significant levels at periods III (vs. groups 2 and 3; P<.05) and IV (vs. group 3; P<.01). A twofold increase of leptin concentration from period I to period II (P<.05) was observed in all groups.

CONCLUSION(S)

The change pattern in serum leptin concentration might provide a great contribution to the pathophysiology development of OHSS patients during assisted reproductive treatment.

Effects of coasting on the outcome of intracytoplasmic sperm injection-embryo transfer cycles

OBJECTIVES

To determine the effects of 'coasting' on the outcome of controlled ovarian hyperstimulation (COH) and intracytoplasmic sperm injection-embryo transfer (ICSI-ET).

DESIGN

Retrospective study.

SETTING

IVF Centre, Ozel Ege Tup Bebek Merkezi, Izmir, Turkey.

SAMPLE

Twenty-six coasted and 52 non-coasted COH and ICSI-ET patients were enrolled in this retrospective study.

METHODS

Coasted patients were enrolled consecutively during the study period, and two non-coasted controls were selected from our database for each coasted patient. Coasting was decided when serum oestradiol level was > or = 4000 pg/mL. Groups were compared using chi2 and Mann-Whitney U-tests for statistical analysis.

MAIN OUTCOME MEASURES

Number of oocytes collected, metaphase II (MII) oocytes and cleaving embryos, the fertilisation rate and clinical pregnancy rate were the main outcome measures.

RESULTS

Number of oocytes collected, number of MII oocytes, number of cleaving embryos, fertilisation rate and clinical pregnancy rate for the coasted and non-coasted groups were 15.5 +/- 5.2 and 14.0 +/- 7.1, 9.7 +/- 4.8 and 9.3 +/- 3.9, 6.8 +/- 3.9 and 5.8 +/- 3.1, 0.85 +/- 0.18 and 0.78 +/- 0.18, 13/26 and 24/52, respectively; these differences were not statistically significant. None of the patients in the coasted group were hospitalised for signs or findings of severe ovarian hyperstimulation syndrome.

CONCLUSIONS

Coasting does not adversely affect the number and the function of mature oocytes and the clinical pregnancy rate.

Predictors of success during the coasting period in high-responder patients undergoing controlled ovarian stimulation for assisted conception

OBJECTIVE

To determine the prognostic factors analyzed during the coasting period that can be used to predict outcomes of IVF cycles.

DESIGN

Retrospective review of data from a single center.

SETTING

Referral private IVF center.

PATIENT(S)

Three hundred forty-six patients who were coasted for the prevention of ovarian hyperstimulation syndrome (OHSS) and 262 patients who were not coasted but having excessive E(2) levels during controlled ovarian hyperstimulation for assisted conception.

INTERVENTION(S)

Controlled ovarian hyperstimulation, oocyte retrieval, intracytoplasmic sperm injection, and embryo transfer.

MAIN OUTCOME MEASURE(S)

Number of total oocytes retrieved, oocyte maturity, fertilization, implantation and pregnancy rates (IR and PR, respectively), and incidence of severe OHSS.

RESULT(S)

No difference was found between early onset coasted patients, late onset coasted patients, and uncoasted patients in terms of fertilization rates, IR, PR, and incidence of severe OHSS. Fertilization and PR did not correlate significantly with decreases in E(2) level during the coasting period. Implantation rates and PR in patients who were coasted > or =4 days were significantly reduced compared with patients who were coasted for 1-3 days. In logistic regression model, the decrease in PR with prolonged coasting was found to be significant; however, there was no correlation between decreased PR and the decrease in E(2) levels during the coasting period.

CONCLUSION(S)

Coasting can be applied safely to controlled hyperstimulation cycles without compromising the outcome. The duration of coasting seems to be a prognostic factor for the outcome of IVF. The criteria for initiation of coasting should be based on clinical experience and assessment of the patient.

Extended coasting duration exerts a negative impact on IVF cycle outcome due to premature luteinization

Coasting, or withholding gonadotrophin administration while maintaining gonadotrophin-releasing hormone analogue until oestradiol drops to a safe concentration, is an alternative approach to prevent ovarian hyperstimulation syndrome (OHSS) in high responder patients. However, the length of this procedure has not been precisely studied. This paper is a retrospective study of 132 patients who showed a high response (oestradiol > 4500 pg/ml and/or more than 20 follicles > 17 mm) to ovarian stimulation and were coasted due to their high risk of developing OHSS, and evaluated the impact of the duration of coasting on IVF cycle outcome. Additionally, serum LH and progesterone concentrations were studied to investigate whether premature luteinization was present in these cycles and whether it might be related to coasting duration. A significant decrease in implantation rate was found when coasting was required for more than 4 days, together with a trend towards a higher cancellation rate. Premature luteinization was significantly elevated in women undergoing coasting compared with control women (34 versus 15.6%, P < 0.05). In the majority of patients who showed premature luteinization, coasting lasted >/=3 days. To conclude, prolonged coasting may affect the endometrium, anticipating the implantation window. These data may explain why some women undergoing extended coasting show a lower implantation rate compared with controls.

Clinical and laboratory evaluation of hospitalized patients with severe ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is an important complication of ovarian stimulation and IVF that enhances patients' morbidity. To evaluate any increased incidence of hospitalization from severe OHSS during 2000, this study analysed certain clinical, ultrasound and laboratory characteristics of hospitalized patients with severe OHSS. These studies were carried out on women undergoing IVF who were hospitalized because of severe OHSS between 1996 and 2000 at the Hôpital Antoine Béclère. Patients' ages and serum hormone concentrations were collected on day 3 of ovarian stimulation for various assays, and laboratory and ultrasound measurements taken during ovarian stimulation for IVF were compared. An increase was noted during last year in the frequency of the severe form of OHSS requiring hospitalization (0.9 versus 1.8%, P < 0.05). Patients' ages and hormonal characteristics on day 3 of menstrual cycle, and laboratory and ultrasound variables were similar between the two groups. In addition, the increased incidence of OHSS during 2000 was not associated with any special laboratory or ultrasound parameter, and the policy of ovarian induction had not changed. It is essential to introduce a simple ovarian stimulation protocol providing acceptable IVF results with a minimum of risk.