An aggressive philosophy in controlled ovarian stimulation cycles increases pregnancy rates

Is the probability of pregnancy after ovarian stimulation for IVF associated with serum estradiol levels on the day of triggering final oocyte maturation with hCG? A systematic review and meta-analysis

PURPOSE

The objective of this systematic review and metaanalysis was to examine if the probability of pregnancy after ovarian stimulation for in vitro fertilization (IVF), using GnRH analogues and gonadotrophins is associated with serum estradiol level (Ε₂) on the day of triggering final oocyte maturation with human chorionic gonadotrophin (hCG).

METHODS

Twenty-one studies were eligible for this systematic review, including 19,598 IVF cycles, whereas three studies were eligible for metaanalysis, including 641 IVF cycles. The main outcome measure was achievement of ongoing pregnancy/live birth and, if not available, clinical pregnancy or biochemical pregnancy.

RESULTS

Pooling of data showed no differences in the probability of clinical pregnancy between patients with high and low Ε₂ levels on the day of triggering final oocyte maturation. The pooled effect sizes for the Ε₂ thresholds groups constructed, regarding clinical pregnancy were 2000-3000 pg/mL-OR 0.91, 95% CI 0.55 to 1.50, (fair quality/moderate risk of bias, n = 1 study), 3000-4000 pg/mL-OR 0.89, 95% CI 0.46 to 1.70, (fair quality/moderate risk of bias, n = 1 study, good quality/no information on which to base a judgement about risk of bias n = 2 studies), 4000-5000 pg/mL-OR 0.74, 95% CI 0.37 to 1.49 fair quality/moderate risk of bias, n = 1 study), 5000-6000 pg/mL-OR 0.62, 95% CI 0.19 to 1.98, (fair quality/moderate risk of bias, n = 1 study). In addition, no difference was observed in the probability of ongoing pregnancy for the Ε₂ threshold group of 3000-4000 pg/mL OR 0.85, 95% CI 0.40 to 1.81(good quality/no information on which to base a judgement about risk of bias, n = 1 study).

CONCLUSION

Currently, there is insufficient evidence to support or deny the presence of an association between the probability of pregnancy and serum Ε₂ levels on the day of triggering final oocyte maturation with hCG in women undergoing ovarian stimulation for IVF.

The impact of supraphysiologic serum estradiol levels on peri-implantation embryo development and early pregnancy outcome following in vitro fertilization cycles

PURPOSE

To determine the impact of elevated serum estradiol levels (EE2-defined as levels > 90th percentile) on the day of hCG administration during IVF on oocyte fertilization, embryo development, implantation, clinical pregnancy and miscarriage rates.

METHODS

A total of 2,995 consecutive IVF cycles in 1,889 patients with non-donor oocyte retrieval resulting in fresh embryo transfer between 1/1/2005 and 12/31/2011 were analyzed. Cycles were stratified by serum E2 level on the day of hCG administration into those with levels >90th percentile and ≤ 90th percentile. Rates of normal fertilization, embryo development, positive pregnancy test, implantation, clinical pregnancy and spontaneous miscarriage were compared.

RESULTS

Serum estradiol above the 90th percentile on the day of hCG administration was associated with a significantly lower rate of normal fertilization (68.6 ± 20 vs. 71.6 ± 21, p = 0.02) when compared with patients with a lower serum estradiol threshold. The proportion of embryos that progressed from 2PN to 6-8 cell on day 3 was not different between the two groups. Although rates of positive pregnancy test (55.2 % vs. 57 %), implantation (26.4 % vs. 28.5 %) and clinical pregnancy (45.5 % vs. 49.4 %) were lower in patients with a higher estradiol threshold, these differences were not statistically significant. Similarly, there was no difference in the spontaneous miscarriage rates between the two groups (8.4 % vs. 7.1 %).

CONCLUSIONS

Serum estradiol levels above the 90th percentile on the day of hCG administration is associated with lower oocyte fertilization rate; however, such levels do not impact embryo development, implantation, clinical pregnancy or spontaneous miscarriage rates.

The significance of antral follicle count in controlled ovarian stimulation and intrauterine insemination

PURPOSE

This retrospective study evaluated the role of antral follicle count (AFC) in predicting ovarian response and successful outcome of stimulated insemination cycles.

METHODS

One-hundred and fifty infertile women with bilateral patent tubes receiving a standard regime of human menopausal gonadotrophin (HMG) in their first cycle were evaluated. Multiple regression analysis was used to evaluate the effects of different parameters on ovarian responses and multiple logistic regression analysis was applied to determine which parameters gave the maximum discrimination to predict clinical pregnancy.

RESULTS

Body mass index was the only significant parameter to predict the number of follicles > or =14 mm whereas AFC was the only significant parameter to predict the HMG duration. Only the number of follicles > or =14 mm significantly improved the chance of clinical pregnancy with an odds ratio of 1.8.

CONCLUSION

AFC was related to the HMG duration but was not predictive of number of follicles and clinical pregnancy of stimulated insemination cycles.

Role of rescue IVF-ET treatment in the management of high response in stimulated IUI cycles

Rescue in-vitro fertilisation and embryo transfer (IVF-ET) has been used in high response gonadotrophin intrauterine insemination (IUI) cycles to minimise the risks of ovarian hyperstimulation and multiple gestation. Such unplanned IVF treatment increases the cost of treatment. But can this added cost and the risks associated with IVF be justified? We present our experience with this treatment using clinical pregnancy and live birth rates as the primary outcomes. Between 1998 to 2001, 40 women undergoing IUI cycles who over responded (>3 follicles measuring >15 mm in diameter on the planned day of hCG administration) to gonadotrophin were offered the choice of conversion to IVF-ET or cancel the cycle. 17/40 declined rescue IVF/ET and had their cycles cancelled. 23/40 converted to IVF/ET and underwent transvaginal oocyte retrieval. 21/23 had embryo transferred. The clinical pregnancy and live birth rates were 52% and 48%, respectively. Rescue IVF-ET offers excellent clinical pregnancy and live birth rates in high responders. However, affordability can be an obstacle in the utilization of this treatment option.

Association of estradiol levels on the day of hCG administration and pregnancy achievement in IVF: a systematic review

BACKGROUND

Evaluation of the association between estradiol (E2) levels on the day of hCG administration and pregnancy achievement in IVF has so far yielded conflicting results. The purpose of the present study was to systematically review the above association in cycles down-regulated with GnRH analogues.

METHODS

Literature search was performed using Medline, Embase (1978-2004) and the Cochrane Library. Additionally, references of retrieved articles were hand-searched. Only full articles published in peer-reviewed medical journals were considered for analysis.

RESULTS

All the eligible studies (n=9) involved the use of GnRH agonists and were retrospective. Two studies (including 191 patients) suggested that the higher the E2 levels on the day of hCG administration, the higher the probability of pregnancy. However, five studies (including 1875 patients), did not support an association between E2 levels on the day of hCG administration and pregnancy rates. Moreover, two of the studies including (1286 patients) suggested that high E2 levels on the day of hCG administration are associated with a decreased probability of pregnancy. If we consider only studies in which criteria used for administering hCG include follicular development but not E2 levels (including 2687 patients), there is no study suggesting a positive association between E2 levels on the day of hCG administration and pregnancy achievement.

CONCLUSIONS

Currently there is no high-quality evidence to support or deny the value of E2 determination on the day of hCG administration for pregnancy achievement in IVF cycles, where pituitary down-regulation is performed with GnRH agonists. Existing retrospective studies suggest that there is no positive association. However, in order to arrive at recommendations for clinical practice, there is a need to perform well-designed prospective studies in both agonist and antagonist cycles.

A prospective, randomized controlled trial comparing the efficacy of recombinant follicle-stimulating hormone in three different in vitro fertilization protocols

OBJECTIVE

To compare the following IVF protocols: a short protocol and long protocols starting on day 2 or day 21. All protocols used recombinant FSH (rFSH) for ovarian stimulation.

DESIGN

Prospective, randomized study.

SETTING

An assisted reproduction unit at a university center.

PATIENT(S)

Patients undergoing IVF (n = 150) were treated according to one of the three treatment protocols allocated by a random method.

INTERVENTION(S)

All patients used buserelin acetate and rFSH. Patients began the long protocol on day 2 (group 1) or day 21 (group 2) of the cycle. Patients in group 3 began the short protocol on day 2 of the cycle.

MAIN OUTCOME MEASURE(S)

Ovarian response, implantation rates, and pregnancy rates (PRs).

RESULT(S)

Patients treated with the short protocol (group 3) were stimulated in a shorter time, required less rFSH, and achieved higher E(2) levels. The numbers of follicles, oocytes, and embryos were similar in all three groups. The implantation rates were similar in groups 1 and 2 (11.8% and 13.3%, respectively), and both were higher than in group 3 (4.1%). Clinical PRs per oocytes retrieved were 19.6%, 18.6%, and 8.3% in groups 1, 2, and 3, respectively.

CONCLUSION(S)

The implantation rate was significantly higher with the long protocols than with the short protocol, with a tendency for a higher PR as well.

"Coasting" does not adversely affect cycle outcome in a subset of highly responsive in vitro fertilization patients

OBJECTIVE

To study the effect of postponing hCG administration while continuing daily GnRH agonist therapy ("coasting") on highly responsive patients undergoing IVF-ET.

DESIGN

Retrospective analysis.

SETTING

University-affiliated Center for Fertility and Reproductive Medicine.

PATIENT(S)

Patients undergoing IVF-ET from March 1995 to March 1997.

INTERVENTION(S)

Three groups of IVF-ET patients were compared to explore the effect of coasting on cycle outcome: a group of highly responsive coasted patients, a group of equally responsive noncoasted patients, and an age-matched normally responsive control group. Two groups of coasted patients were also compared to assess the effect of E2 levels at the time that they met the follicular criteria for hCG administration. Last, the effect of varying coast duration was examined by regression analysis.

MAIN OUTCOME MEASURE(S)

Patient characteristics, outcome parameters, and incidence of ovarian hyperstimulation syndrome (OHSS).

RESULT(S)

Coasting had no detrimental effect on cycle outcome in the subset studied. Regression analysis, however, suggests an inverse relationship between coast duration and the number of mature oocytes retrieved as well as the clinical pregnancy rate.

CONCLUSION(S)

Coasting in the studied subset of IVF patients did not adversely affect cycle outcome parameters or the incidence of OHSS, but prolonged coasting intervals may impair IVF cycle outcome.

Confounding variables affecting in vitro fertilization success: a decade of experience

PURPOSE

To evaluate etiology of infertility, female age, ovarian response and stimulation protocol in affecting in vitro fertilization (IVF) success.

METHODS

Retrospective analysis was used. Computer records of all 5209 cycles initiated in 2391 couples from February 1, 1984 to December 31, 1993 were analyzed.

RESULTS

There were 644 intrauterine, 24 solely ectopic and 7 heterotopic pregnancies. Pregnancy rates increased with number of embryos transferred with a significant increase still found between transfer of three or four embryos. Multiple gestations also increased in association with an increasing number of embryos transferred. Pregnancy rates per cycle did not decline with repeated cycles. Reduced pregnancy rates were associated with a primary diagnosis of male infertility. Covariates associated with a better pregnancy rate were younger age of the female partner or higher peak preovulatory serum estradiol. Routine administration of GnRH-agonist was associated with a reduced cycle cancellation rate, an increase in oocytes retrieved and an improved pregnancy rate.

CONCLUSIONS

Couples with male infertility and increased female age should be counselled regarding the reduced prognosis for success.