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Lin J, Wu F, Zhu Y, Wang B, Cao Z, Lin J. Letrozole co-treatment in an antagonist protocol for overweight women undergoing IVF treatment: a retrospective study. BMC Pregnancy Childbirth 2024; 24:592. [PMID: 39256667 PMCID: PMC11386352 DOI: 10.1186/s12884-024-06795-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 08/29/2024] [Indexed: 09/12/2024] Open
Abstract
BACKGROUND Overweight women undergoing IVF treatment have lower success rates. Letrozole, an aromatase inhibitor, has been used as an adjunct for IVF treatment, but its specific effects in overweight women have not been investigated. This study was to explore the effects of letrozole co-treatment in an antagonist protocol for overweight infertile women undergoing IVF treatment. METHODS This retrospective cohort study included overweight infertile women who underwent IVF/ICSI treatment and fresh embryo transfer (ET), with or without letrozole co-treatment in an antagonist protocol, from 2007 to 2021 at Shanghai Ninth People's Hospital (Shanghai, China). A total of 704 overweight infertile women were included: 585 women were in the antagonist group, and 119 women were in the letrozole co-treatment group. The primary outcome was the live birth rate after fresh ET. Propensity score-based patient-matching was employed to balance the covariates between the groups. Multivariate logistic regression analysis was also performed to estimate odds ratio (OR) and 95% confidence interval (CI) for association of letrozole co-treatment and the live birth outcome. RESULTS Letrozole co-treatment induced significant changes in hormonal profile on the trigger day. The letrozole group exhibited a decrease in the total number of follicles compared to the antagonist group, but a higher proportion of large follicles at oocyte retrieval (P < 0.05). The quantity and quality of embryos were comparable between the two groups (P > 0.05). The letrozole co-treatment group had a significantly higher live birth rate than the control group (38.7% vs. 22.6%, P = 0.026). With multivariate logistic regression analysis, letrozole co-treatment was associated with higher odds of live birth after adjusting for potential confounding factors (adjusted OR = 2.00, 95% CI = 1.17-3.39, P = 0.011). Letrozole presented no significant associations with obstetrical or neonatal complications (P > 0.05). CONCLUSION Letrozole co-treatment in an antagonist protocol may offer potential benefits for overweight infertile women undergoing IVF treatment. Further research is warranted to validate these findings and explore the broader implications for letrozole co-treatment.
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Affiliation(s)
- Jing Lin
- Center for Reproductive Medicine, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fenglu Wu
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yanwen Zhu
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bian Wang
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhengjun Cao
- Department of Gynaecology and Obstetrics, Shanghai Putuo People's Hospital of Tongji University, Shanghai, China.
| | - Jiaying Lin
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Lin J, Wu F, Zhu Y, Zhu Q, Du T, Lin J. The Efficacy of Letrozole Co-Treatment in an Antagonist Protocol for Women with Polycystic Ovary Syndrome Undergoing IVF: A Retrospective Study. Drug Des Devel Ther 2024; 18:2823-2835. [PMID: 39006189 PMCID: PMC11244072 DOI: 10.2147/dddt.s458608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 06/27/2024] [Indexed: 07/16/2024] Open
Abstract
Objective Our objective was to investigate the efficacy of letrozole co-treatment in an antagonist protocol for infertile women with polycystic ovary syndrome (PCOS). Patients and Methods This retrospective cohort study included infertile women with PCOS undergoing IVF/ICSI with and without letrozole co-treatment in an antagonist protocol from 2007-2021 at Shanghai Ninth People's Hospital (Shanghai, China). A total of 1559 participants were enrolled, with 1227 women in the antagonist group and 332 women in the letrozole co-treatment group. Propensity score-based patient-matching model was conducted to balance covariates between the groups. The primary outcome was the number of retrieved oocytes, with secondary outcomes including endocrine parameters, ovarian stimulation outcomes, pregnancy outcomes, and obstetrical and neonatal complications. Results Letrozole co-treatment induced significant changes in hormonal regulation, increased the percentage of large follicles, and resulted in fewer retrieved oocytes (P < 0.05). However, there was no negative impact on the number of usable embryos or good-quality embryos (P > 0.05). The live birth rates following fresh embryo transfer were comparable between the letrozole and control groups (single embryo transfer: 28.9% vs 29.7%, P > 0.05; double embryo transfer: 37.3% vs 45.6%, P > 0.05). Additionally, there were no significant differences between the two groups in the live birth rate per patient after frozen embryo transfer and the cumulative live birth rate (P > 0.05). No significant differences in obstetrical and neonatal complications were observed between the groups (P > 0.05). Conclusion The addition of letrozole to the antagonist protocol for women with PCOS undergoing IVF induces a higher percentage of large follicles during oocyte retrieval, while reducing the overall number of retrieved oocytes. Moreover, the use of letrozole demonstrates comparable clinical outcomes following embryo transfers. These findings highlight the potential application of letrozole in an antagonist protocol for women with PCOS.
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Affiliation(s)
- Jing Lin
- Center for Reproductive Medicine, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
| | - Fenglu Wu
- Department of Assisted Reproduction, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
| | - Yanwen Zhu
- Department of Assisted Reproduction, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
| | - Qianqian Zhu
- Department of Assisted Reproduction, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
| | - Tong Du
- Department of Assisted Reproduction, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
| | - Jiaying Lin
- Department of Assisted Reproduction, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
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Bülow NS, Warzecha AK, Nielsen MV, Andersen CY, Holt MD, Petersen MR, Sopa N, Zedeler A, Englund AL, Pinborg A, Grøndahl ML, Skouby SO, Macklon NS. Impact of letrozole co-treatment during ovarian stimulation on oocyte yield, embryo development, and live birth rate in women with normal ovarian reserve: secondary outcomes from the RIOT trial. Hum Reprod 2023; 38:2154-2165. [PMID: 37699851 DOI: 10.1093/humrep/dead182] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 07/27/2023] [Indexed: 09/14/2023] Open
Abstract
STUDY QUESTION Does letrozole (LZ) co-treatment during ovarian stimulation with gonadotropins for in IVF impact follicle recruitment, oocyte number and quality, embryo quality, or live birth rate (LBR)? SUMMARY ANSWER No impact of LZ was found in follicle recruitment, number of oocytes, quality of embryos, or LBR. WHAT IS KNOWN ALREADY Multi-follicle stimulation for IVF produces supra-physiological oestradiol levels. LZ is an aromatase inhibitor that lowers serum oestradiol thus reducing negative feedback and increasing the endogenous gonadotropins in both the follicular and the luteal phases, effectively normalizing the endocrine milieu during IVF treatment. STUDY DESIGN, SIZE, DURATION Secondary outcomes from a randomized, double-blind placebo-controlled trial (RCT) investigating once-daily 5 mg LZ or placebo during stimulation for IVF with FSH. The RCT was conducted at four fertility clinics at University Hospitals in Denmark from August 2016 to November 2018 and pregnancy outcomes of frozen-thawed embryo transfers (FET) registered until May 2023. PARTICIPANTS/MATERIALS, SETTING, METHODS One hundred fifty-nine women with expected normal ovarian reserve (anti-Müllerian hormone 8-32 nmol/l) were randomized to either co-treatment with LZ (n = 80) or placebo (n = 79). In total 1268 oocytes were aspirated developing into 386 embryos, and morphology and morphokinetics were assessed. One hundred twenty-nine embryos were transferred in the fresh cycle and 158 embryos in a subsequent FET cycle. The effect of LZ on cumulative clinical pregnancy rate (CPR), LBR, endometrial thickness in the fresh cycle, and total FSH consumption was reported. MAIN RESULTS AND THE ROLE OF CHANCE The proportion of usable embryos of retrieved oocytes was similar in the LZ group and the placebo group with 0.31 vs 0.36 (mean difference (MD) -0.05, 95% CI (-0.12; 0.03), P = 0.65). The size and number of aspirated follicles at oocyte retrieval were similar with 11.8 vs 10.3 follicles per patient (MD 1.5, 95% CI (-0.5; 3.1), P = 0.50), as well as the number of retrieved oocytes with 8.0 vs 7.9 oocytes (MD 0.1, 95% CI (-1.4; 1.6), P = 0.39) in the LZ and placebo groups, respectively. The chance of retrieving an oocyte from the 13 to 16 mm follicles at trigger day was 66% higher (95% CI (24%; 108%), P = 0.002) in the placebo group than in the LZ group, whilst the chance of retrieving an oocyte from the ≥17 mm follicles at trigger day was 50% higher (95% CI (2%; 98%), P = 0.04) in the LZ group than in the placebo group. The proportion of fertilized oocytes with two-pronuclei per retrieved oocytes or per metaphase II oocytes (MII) (the 2PN rates) were similar regardless of fertilization with IVF or ICSI with 0.48 vs 0.57 (MD -0.09, 95% CI (-0.24; 0.04), P = 0.51), and 0.62 vs 0.64 (MD -0.02, 95% CI (-0.13; 0.07), P = 0.78) in the LZ and placebo groups, respectively. However, the MII rate in the ICSI group was significantly lower with 0.75 vs 0.88 in the LZ vs the placebo group (MD -0.14, 95% CI (-0.22; -0.06), P = 0.03). Blastocysts on Day 5 per patient were similar with 1.5 vs 2.0, P = 0.52, as well as vitrified blastocysts per patient Day 5 with 0.8 vs 1.2 in (MD -0.4, 95% CI (-1.0; 0.2), P = 0.52) and vitrified blastocysts per patient Day 6 with 0.6 vs 0.6 (MD 0, 95% CI (-0.3; 0.3), P = 1.00) in the LZ vs placebo group, respectively. Morphologic evaluation of all usable embryos showed a similar distribution in 'Good', 'Fair', and 'Poor', in the LZ vs placebo group, with an odds ratio (OR) of 0.8 95% CI (0.5; 1.3), P = 0.68 of developing a better class embryo. Two hundred and ninety-five of the 386 embryos were cultured in an embryoscope. Morphokinetic annotations showed that the odds of having a high KIDscore™ D3 Day 3 were 1.2 times higher (CI (0.8; 1.9), P = 0.68) in the LZ group vs the placebo group. The CPR per transfer was comparable with 31% vs 39% (risk-difference of 8%, 95% CI (-25%; 11%), P = 0.65) in the LZ and placebo group, respectively, as well as CPR per transfer adjusted for day of transfer, oestradiol and progesterone levels at trigger, progesterone levels mid-luteal, and number of oocytes retrieved (adjusted OR) of 0.8 (95% CI (0.4; 1.6), P = 0.72). Comparable LBR were found per transfer 28% vs 37% (MD -9%, 95% CI (-26%; 9%), P = 0.60) and per randomized women 24% vs 30% (MD of -6%, CI (-22%; 8%), P = 0.60) in the LZ group and placebo group, respectively. Furthermore, 4.8 years since the last oocyte aspiration, a total of 287 of 386 embryos have been transferred in the fresh or a subsequently FET cycle, disclosing the cumulative CPR, which is similar with 38% vs 34% (MD 95% CI (8%; 16%), P = 0.70) in the LZ vs placebo group. LIMITATIONS, REASONS FOR CAUTION Both cleavage stage and blastocyst transfer and vitrification were permitted in the protocol, making it necessary to categorize their quality and pool the results. The study was powered to detect hormonal variation but not embryo or pregnancy outcomes. WIDER IMPLICATIONS OF THE FINDINGS The similar utilization rate and quality of the embryos support the use of LZ co-treatment for IVF with specific indication as fertility preservation, patients with previous cancer, or poor responders. The effect of LZ on mature oocytes from different follicle sizes and LBRs should be evaluated in a meta-analysis or a larger RCT. STUDY FUNDING/COMPETING INTEREST(S) Funding was received from EU Interreg for ReproUnion, Sjaelland University Hospital, Denmark, Ferring Pharmaceuticals, and Gedeon Ricther. Roche Diagnostics contributed with assays. A.P. has received grants from Ferring, Merck Serono, and Gedeon Richter, consulting fees from Preglem, Novo Nordisk, Ferring, Gedeon Richter, Cryos, & Merck A/S, speakers fees from Gedeon Richter, Ferring, Merck A/S, Theramex, & Organon, and travel support from Gedeon Richter. The remaining authors declare that they have no competing interests in the research or publication. TRIAL REGISTRATION NUMBERS NCT02939898 and NCT02946684.
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Affiliation(s)
- Nathalie Søderhamn Bülow
- Department of Obstetrics and Gynaecology, Endocrinological and Reproductive Unit, Copenhagen University Hospital, Herlev Hospital, Copenhagen, Denmark
- The Fertility Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Agnieszka Katarzyna Warzecha
- Department of Obstetrics and Gynaecology, Endocrinological and Reproductive Unit, Copenhagen University Hospital, Herlev Hospital, Copenhagen, Denmark
| | - Mette Villads Nielsen
- Department of Obstetrics and Gynaecology, Endocrinological and Reproductive Unit, Copenhagen University Hospital, Herlev Hospital, Copenhagen, Denmark
| | - Claus Yding Andersen
- Faculty of Health and Medical Sciences, Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Marianne Dreyer Holt
- Department of Obstetrics and Gynaecology, The Fertility Department, Zealand University Hospital Køge, Køge, Denmark
| | - Morten Rønn Petersen
- The Fertility Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Negjyp Sopa
- Department of Obstetrics and Gynaecology, The Fertility Clinic, Copenhagen University Hospital, Hvidovre, Denmark
| | - Anne Zedeler
- Department of Obstetrics and Gynaecology, The Fertility Clinic, Copenhagen University Hospital, Hvidovre, Denmark
| | - Anne Lis Englund
- Department of Obstetrics and Gynaecology, The Fertility Department, Zealand University Hospital Køge, Køge, Denmark
| | - Anja Pinborg
- The Fertility Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Obstetrics and Gynaecology, The Fertility Clinic, Copenhagen University Hospital, Hvidovre, Denmark
| | - Marie Louise Grøndahl
- Department of Obstetrics and Gynaecology, Endocrinological and Reproductive Unit, Copenhagen University Hospital, Herlev Hospital, Copenhagen, Denmark
| | - Sven Olaf Skouby
- Department of Obstetrics and Gynaecology, Endocrinological and Reproductive Unit, Copenhagen University Hospital, Herlev Hospital, Copenhagen, Denmark
| | - Nicholas Stephen Macklon
- Department of Obstetrics and Gynaecology, The Fertility Department, Zealand University Hospital Køge, Køge, Denmark
- London Women's Clinic, London, UK
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D’Amato G, Caringella AM, Stanziano A, Cantatore C, D’Amato A, Cicinelli E, Vitagliano A. Corifolitropin-Alfa plus Five Days Letrozole Versus Daily Recombinant-FSH in Expected Normo-Responder Patients: A Retrospective Comparative Study. Diagnostics (Basel) 2023; 13:diagnostics13071249. [PMID: 37046467 PMCID: PMC10092944 DOI: 10.3390/diagnostics13071249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/16/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023] Open
Abstract
Background: In recent times, different novel GnRH-antagonist protocols with various combinations of gonadotropins and other molecules (e.g., aromatase inhibitors, selective estrogen receptor modulators) have been proposed for expected normal ovarian responders undergoing assisted reproductive treatments. The purpose of this study was to evaluate the effectiveness of a novel ovarian stimulation protocol based on the combination of corifollitropin-alfa plus five days of letrozole in E-NOR women undergoing IVF as compared with a daily recombinant-FSH regimen. Methods: We conducted a retrospective-controlled study on 182 couples undergoing their first IVF attempt. In Group A (experimental), letrozole (2.5 mg daily) was administered from day 2 (up to day 6 of the cycle), followed by corifollitropin-alfa on day 3 and daily recombinant FSH from day 10. In Group B, recombinant FSH from day 2 were administered (150 IU-225 IU daily). Statistical analysis was completed using SPSS Statistics. The primary outcome was the total number of MII oocytes retrieved. Results: Group A showed similar results compared to Group B in terms of MII oocytes, live birth, implantation, and clinical pregnancy rates (p = ns). Nevertheless, the experimental group was associated with a trend towards a higher number of developing follicles, total oocytes, and embryos (p < 0.05) with lower estradiol and progesterone values at ovulation induction compared to Group B, resulting in an increased chance of performing a fresh embryo transfer (p < 0.05). Conclusions: The combination of CFα plus five days of letrozole was associated with a trend towards a higher number of developing follicles, total oocytes, and obtained embryos. Moreover, the experimental protocol resulted in lower estradiol and progesterone values at ovulation induction compared to daily rFSH, with an increased chance of performing a fresh embryo transfer (with no OHSS occurrence). Given the observational design of our study, further well-conducted RCTs are needed.
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Affiliation(s)
- Giuseppe D’Amato
- Department of Advanced Reproductive Risk Management and High-Risk Pregnancies, ASL Bari, Reproductive and IVF Unit, PTA “F Jaia”, 70014 Conversano, BA, Italy
| | - Anna Maria Caringella
- Department of Advanced Reproductive Risk Management and High-Risk Pregnancies, ASL Bari, Reproductive and IVF Unit, PTA “F Jaia”, 70014 Conversano, BA, Italy
| | - Antonio Stanziano
- Department of Advanced Reproductive Risk Management and High-Risk Pregnancies, ASL Bari, Reproductive and IVF Unit, PTA “F Jaia”, 70014 Conversano, BA, Italy
| | - Clementina Cantatore
- Department of Advanced Reproductive Risk Management and High-Risk Pregnancies, ASL Bari, Reproductive and IVF Unit, PTA “F Jaia”, 70014 Conversano, BA, Italy
| | - Antonio D’Amato
- Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari, 70100 Bari, BA, Italy
| | - Ettore Cicinelli
- Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari, 70100 Bari, BA, Italy
| | - Amerigo Vitagliano
- Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari, 70100 Bari, BA, Italy
- Correspondence:
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Suzuki R, Horage-Okutsu Y, Kawahara T, Nakamura K, Shiraishi E, Iwahata H, Suzuki-Takahashi Y, Sugishita Y, Takae S, Suzuki N. The effect of aromatase inhibitor on controlled ovarian stimulation for oocyte cryopreservation in adolescent and young cancer patients. J Obstet Gynaecol Res 2023; 49:973-979. [PMID: 36606606 DOI: 10.1111/jog.15535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 12/19/2022] [Indexed: 01/07/2023]
Abstract
AIM To determine the impact of aromatase inhibitor (AI) use in oocyte cryopreservation among Japanese adolescent and young adult (AYA) cancer patients for fertility preservation, we evaluated the oocyte cryopreservation outcomes following AI therapy in combination with the follicular phase start (FPS) and random start (RS) protocols. METHODS This retrospective study included 81 cycles of controlled ovarian stimulation (COS) among 73 AYA patients with cancer who underwent oocyte cryopreservation to maintain fertility. The outcome measures were the total number of matured oocytes that were retrieved and cryopreserved, as well as their maturation rates. The AI (+) and AI (-) groups were compared using the RS and FPS protocols. RESULTS Our results showed that the combined use of AI and COS decreases serum E2 levels and maintains the number of retrieved and cryopreserved mature oocytes. We also confirmed the efficacy of the RS protocol, which was found to have comparable outcomes to that of the FPS protocol in both AI (+) and AI (-) groups. CONCLUSION The combined use of AI and COS is beneficial for oocyte cryopreservation in patients with estrogen-sensitive cancer, regardless of the menstrual cycle phase of COS initiation.
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Affiliation(s)
- Reiko Suzuki
- Department of Obstetrics and Gynecology, Saint Marianna University School of Medicine, Kawasaki, Japan
| | - Yuki Horage-Okutsu
- Department of Obstetrics and Gynecology, Saint Marianna University School of Medicine, Kawasaki, Japan
| | - Tai Kawahara
- Department of Obstetrics and Gynecology, Saint Marianna University School of Medicine, Kawasaki, Japan
| | - Kentaro Nakamura
- Department of Obstetrics and Gynecology, Saint Marianna University School of Medicine, Kawasaki, Japan
| | - Eriko Shiraishi
- Department of Obstetrics and Gynecology, The Jikei University school of medicine, Tokyo, Japan
| | - Hideyuki Iwahata
- Department of Obstetrics and Gynecology, Saint Marianna University School of Medicine, Kawasaki, Japan
| | - Yuki Suzuki-Takahashi
- Department of Obstetrics and Gynecology, Saint Marianna University School of Medicine, Kawasaki, Japan
| | - Yodo Sugishita
- Department of Obstetrics and Gynecology, Saint Marianna University School of Medicine, Kawasaki, Japan
| | - Seido Takae
- Department of Obstetrics and Gynecology, Saint Marianna University School of Medicine, Kawasaki, Japan
| | - Nao Suzuki
- Department of Obstetrics and Gynecology, Saint Marianna University School of Medicine, Kawasaki, Japan
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Liu Y, Lin J, Shen X, Zhu Q, Kuang Y. Letrozole cotreatment improves the follicular output rate in high-body-mass-index women with polycystic ovary syndrome undergoing IVF treatment. Front Endocrinol (Lausanne) 2023; 14:1072170. [PMID: 36936138 PMCID: PMC10020617 DOI: 10.3389/fendo.2023.1072170] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 02/20/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND Women who have polycystic ovary syndrome (PCOS) with high body mass index (BMI) typically have an attenuated ovarian response and decreased follicular size, which are linked to unfavourable clinical outcomes following in vitro fertilization (IVF) therapy. The follicular output rate (FORT), a qualitative indicator of follicular response, seems to be positively linked to the clinical outcomes of IVF. Progestin-primed ovarian stimulation (PPOS) has become an alternative to gonadotropin-releasing hormone (GnRH) analogues to inhibit the premature luteinizing hormone (LH) surge. As letrozole (LE) shows promise in enhancing ovarian response, we compared PPOS with and without LE for PCOS in high BMI women with a focus on the FORT and associated clinical and pregnancy outcomes. METHODS For the recruited 1508 women, ten variables including AFC; age; basal sex hormone level; BMI; infertility type; period of infertility and number of previous IVF attempts were chosen in the propensity score matching (PSM) model to match 1374 women who taken the MPA+ hMG protocol with 134 women who received the MPA+ hMG+ LE treatment at a 1:1 ratio. FORT was selected as the primary outcome measure. The number of oocytes retrieved, viable embryos, hMG dosage, duration, oocyte maturity rate, fertilization rate, and implantation rate were established as secondary outcomes. RESULTS FORT was substantially elevated in the MPA+hMG+LE group compared with the MPA+hMG group (61% [35%, 86%] vs. 40% [25%, 60%], P <.001). Interestingly, the LE cotreatment group had a considerably lower mature oocyte rate despite having a similar number of mature oocytes and embryos recovered. The average hMG dosages and durations in the study group were similar to those in the control group. The implantation rate in the study group was numerically higher but without statistic significant than that in the control groups (43.15% (107/248) vs. 38.59% (115/298), OR 1.008, 95% CI 0.901-1.127; P >.05). CONCLUSION The effect of LE combined with PPOS on FORT is better than the effect of the standard PPOS treatment in women with PCOS and a high BMI, but there is no substantially beneficial impact on pregnancy outcomes or the cycle features of COS, including consumption of hMG.
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Poulsen LC, Bülow NS, Macklon NS, Bungum L, Skouby SO, Yding Andersen C. Reply: Impact of letrozole-associated controlled ovarian hyperstimulation on ART outcomes and endocrinological parameters. Hum Reprod 2022; 37:2723-2724. [PMID: 36124887 DOI: 10.1093/humrep/deac207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- L C Poulsen
- Department of Gynaecology and Obstetrics, Endocrinological and Reproductive Unit, Copenhagen University Hospital, Herlev Hospital, Herlev, Copenhagen, Denmark
| | - N S Bülow
- Department of Gynaecology and Obstetrics, Endocrinological and Reproductive Unit, Copenhagen University Hospital, Herlev Hospital, Herlev, Copenhagen, Denmark.,The Fertility Department, Copenhagen University Hospital, Copenhagen, Denmark
| | - N S Macklon
- Fertility Clinic, Department of Gynaecology and Obstetrics, University Hospital of Region Zealand, Køge, Denmark.,London Women's Clinic, London, UK
| | - L Bungum
- Fertility Clinic, Department of Gynaecology and Obstetrics, University Hospital of Region Zealand, Køge, Denmark
| | - S O Skouby
- Department of Gynaecology and Obstetrics, Endocrinological and Reproductive Unit, Copenhagen University Hospital, Herlev Hospital, Herlev, Copenhagen, Denmark
| | - C Yding Andersen
- Laboratory of Reproductive Biology, Copenhagen University Hospital, Copenhagen, Denmark
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Molecular Genomic Study of Inhibin Molecule Production through Granulosa Cell Gene Expression in Inhibin-Deficient Mice. Molecules 2022; 27:molecules27175595. [PMID: 36080362 PMCID: PMC9458043 DOI: 10.3390/molecules27175595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 08/23/2022] [Accepted: 08/25/2022] [Indexed: 11/17/2022] Open
Abstract
Inhibin is a molecule that belongs to peptide hormones and is excreted through pituitary gonadotropins stimulation action on the granulosa cells of the ovaries. However, the differential regulation of inhibin and follicle-stimulating hormone (FSH) on granulosa cell tumor growth in mice inhibin-deficient females is not yet well understood. The objective of this study was to evaluate the role of inhibin and FSH on the granulosa cells of ovarian follicles at the premature antral stage. This study stimulated immature wild-type (WT) and Inhibin-α knockout (Inha−/−) female mice with human chorionic gonadotropin (hCG) and examined hCG-induced gene expression changes in granulosa cells. Also, screening of differentially expressed genes (DEGs) was performed in the two groups under study. In addition, related modules to external traits and key gene drivers were determined through Weighted Gene Co-Expression Network Analysis (WGCNA) algorithm. The results identified a number of 1074 and 931 DEGs and 343 overlapping DEGs (ODEGs) were shared in the two groups. Some 341 ODEGs had high relevance and consistent expression direction, with a significant correlation coefficient (r2 = 0.9145). Additionally, the gene co-expression network of selected 153 genes showed 122 nodes enriched to 21 GO biological processes (BP) and reproduction and 3 genes related to genomic pathways. By using principal component analysis (PCA), the 14 genes in the regulatory network were fixed and the cumulative proportion of fitted top three principal components was 94.64%. In conclusion, this study revealed the novelty of using ODEGs for investigating the inhibin and FSH hormone pathways that might open the way toward gene therapy for granulosa cell tumors. Also, these genes could be used as biomarkers for tracking the changes in inhibin and FSH hormone from the changes in the nutrition pattern.
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Poulsen LC, Warzecha AK, Bülow NS, Bungum L, Macklon NS, Yding Andersen C, Skouby SO. Effects of letrozole cotreatment on endocrinology and follicle development in women undergoing ovarian stimulation in an antagonist protocol. Hum Reprod 2022; 37:1557-1571. [PMID: 35652260 DOI: 10.1093/humrep/deac119] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 04/17/2022] [Indexed: 12/25/2022] Open
Abstract
STUDY QUESTION What are the downstream endocrine and paracrine consequences of letrozole (LZ) cotreatment during ovarian stimulation and is follicle growth and recruitment affected? SUMMARY ANSWER Letrozole cotreatment induces marked changes in both the follicular and luteal phase endocrinology causing potentiation of follicle diameter and an improved corpus luteum function without affecting the secondarily recruited follicle cohort. WHAT IS KNOWN ALREADY Letrozole is a third-generation aromatase inhibitor that is well-established as an effective ovulatory agent, while its possible benefits in standard in vitro fertilization protocols are less thoroughly investigated. STUDY DESIGN, SIZE, DURATION This study included a double-blinded, placebo-controlled, randomized study with LZ or placebo intervention during ovarian stimulation for IVF treatment, an observational preceding baseline natural cycle and a succeeding follow-up visit. Participants were enrolled between August 2016 and November 2018. Data from the randomized, stimulated cycle were part of a larger RCT, which was previously published. PARTICIPANTS/MATERIALS, SETTING, METHODS The study was conducted at a public fertility clinic at Herlev Hospital, Denmark, including 31 healthy, normo-responding women eligible for IVF treatment. They underwent a natural baseline cycle and were subsequently randomized to receive either LZ 5 mg (n = 16) or placebo (n = 15) daily during ovarian stimulation from cycle day (CD) 2-3 until induction of ovulation. Throughout both cycles, monitoring was performed every third day with transvaginal ultrasound for assessment of follicle count and diameter, and blood analyses for the determination of twelve endocrine and paracrine parameters. A follow-up assessment was performed at CD2-3 in the succeeding cycle. In the randomized part of the study, we determined differences in blood parameters, follicle recruitment, and follicle diameter. In the observational part of the study, we assessed follicle recruitment in between cycles and its correlation to endocrine parameters. MAIN RESULTS AND THE ROLE OF CHANCE Letrozole cotreatment significantly suppressed oestradiol (E2) concentrations in the follicular phase (area under the curve (AUC) -58% (95% CI [-70%; -43%], P < 0.001)) and luteal phase (AUC -39% [-63%; -1%], P = 0.046). This had a marked effect on the endocrine and paracrine output with increased follicular phase luteinizing hormone (AUC +37% [3%; 82%], P = 0.033), androstenedione (AUC +36% [6%; 74%], P = 0.016), testosterone (AUC +37% [7%; 73%], P = 0.013) and 17-OH-progesterone (AUC +114% [10%; 318%], P = 0.027). Furthermore, follicle-stimulating hormone (FSH) was increased at stimulation day 5 in the LZ group (P < 0.05). In the luteal phase, increased corpus luteum output was reflected by elevated progesterone (AUC +44% [1%; 104%], P = 0.043), inhibin A (AUC +52% [11%; 108%], P = 0.011), androstenedione (AUC +31% [9%; 58%], P = 0.006) and testosterone (AUC +29% [6%; 57%], P = 0.012) in the LZ group. The altered balance between oestrogens and androgens was reflected in a markedly reduced SHBG concentration in the LZ group throughout the luteal phase (AUC -35% [-52%; -11%], P = 0.009). Endocrine and paracrine parameters were similar between groups at the follow-up visit. Letrozole cotreatment significantly increased the mean number of follicles >16 mm at oocyte retrieval (7.2 vs 5.2, difference: 2.0, 95% CI [0.1; 3.8], P = 0.036), while the mean total number of follicles at oocyte retrieval was the same (23.7 vs 23.5, difference: 0.2 [-5.8; 6.1], P = 0.958), and the mean FSH consumption during the stimulated cycle was similar (1500 vs 1520 IU, difference -20 IU [-175; 136], P = 0.794). Between cycles, the mean antral follicle count at CD2-3 was unchanged (natural cycle 19.0, stimulated cycle 20.9, follow-up cycle 19.7, P = 0.692) and there was no effect of LZ cotreatment on the recruitment of the next follicle cohort (test for interaction, P = 0.821). LIMITATIONS, REASONS FOR CAUTION This study included a relatively small, selected group of healthy women with an expected normal ovarian function and reserve, and the effects of LZ may therefore be different in other patient groups. WIDER IMPLICATIONS OF THE FINDINGS We confirm some previous findings concerning increased follicle growth and increased endogenous FSH and androgen production, which support the rationale for further studies on the use of LZ cotreatment, for example, as a form of endogenous androgen priming sensitizing the follicle to FSH. Letrozole appears to improve the luteal phase with better stimulation of corpus luteum and progesterone secretion. STUDY FUNDING/COMPETING INTEREST(S) The authors declare no conflicts of interest relating to the present work. TRIAL REGISTRATION NUMBER NCT02939898.
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Affiliation(s)
- Liv C Poulsen
- Department of Gynaecology and Obstetrics, Endocrinological and Reproductive Unit, Copenhagen University Hospital, Herlev Hospital, Herlev, Denmark
| | - Agnieszka K Warzecha
- Department of Gynaecology and Obstetrics, Endocrinological and Reproductive Unit, Copenhagen University Hospital, Herlev Hospital, Herlev, Denmark
| | - Nathalie S Bülow
- Department of Gynaecology and Obstetrics, Endocrinological and Reproductive Unit, Copenhagen University Hospital, Herlev Hospital, Herlev, Denmark.,The Fertility Department, Copenhagen University Hospital, Copenhagen, Denmark
| | - Leif Bungum
- Fertility Clinic, Department of Gynaecology and Obstetrics, Zealand University Hospital, Køge, Denmark
| | - Nicholas S Macklon
- Fertility Clinic, Department of Gynaecology and Obstetrics, Zealand University Hospital, Køge, Denmark.,London Women's Clinic, London, UK
| | - Claus Yding Andersen
- Laboratory of Reproductive Biology, The Juliane Marie Centre for Women, Children and Reproduction, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sven O Skouby
- Department of Gynaecology and Obstetrics, Endocrinological and Reproductive Unit, Copenhagen University Hospital, Herlev Hospital, Herlev, Denmark
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Guo W, Li HWR, Yang Z, Zeng L, Yang R, Qiao J, Li R, Ng EHY. Live birth after letrozole as an adjunct to follicle-stimulating hormone versus follicle-stimulating hormone alone for ovarian stimulation in in vitro fertilisation cycles-study protocol for a randomised controlled trial. Trials 2022; 23:247. [PMID: 35365197 PMCID: PMC8973630 DOI: 10.1186/s13063-022-06185-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/18/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION In vitro fertilisation (IVF) is an effective infertility treatment but the live birth rate remains unsatisfactory. Ovarian stimulation by follicle-stimulating hormone (FSH) is routinely used in IVF and the resulting high serum estradiol levels may impair oocyte/embryo quality and endometrial receptivity. Letrozole, an aromatase inhibitor, can reduce serum estradiol levels following ovarian stimulation. We aim to test the hypothesis that co-treatment with letrozole reduces supraphysiological serum estradiol levels and improves endometrial receptivity, leading to a higher live birth rate of IVF. We are conducting a randomised controlled trial (RCT) to evaluate whether letrozole as an adjunct to FSH in IVF is superior to FSH alone in the live birth rate of fresh embryo transfer. METHODS/DESIGN This is an open-label randomised controlled superiority trial being performed in two assisted reproduction centres in China. Infertile women who have antral follicle count (AFC) before ovarian stimulation or on day 5 of ovarian stimulation ≥15 are randomly allocated in a 1:1 ratio to receive either letrozole and FSH or FSH alone in a GnRH antagonist protocol. Recruited women follow the standard operating procedures of the two centres. The primary outcome is the live birth rate of the fresh embryo transfer. Stimulation parameters, maternal side effects and obstetric and perinatal complications are secondary outcomes. The planned sample size is 900, i.e. 450 per group. DISCUSSION The present study is the first multicentre randomised study to compare the live birth rate of the fresh embryo transfer following ovarian stimulation by letrozole and FSH versus FSH alone in women with anticipated high ovarian responses. TRIAL REGISTRATION ClinicalTrials.gov NCT02912988 . Registered on September 23, 2016. This trial protocol is version 2.0.
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Affiliation(s)
- Wei Guo
- Centre for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, No.49 North Huayuan Road, Haidian District, Beijing, 100191 China
- National Clinical Research Centre for Obstetrics and Gynecology, Beijing, 100191 China
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing, 100191 China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, 100191 China
| | - Hang Wun Raymond Li
- Department of Obstetrics and Gynaecology, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong, Special Administrative Region China
| | - Zi Yang
- Centre for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, No.49 North Huayuan Road, Haidian District, Beijing, 100191 China
- National Clinical Research Centre for Obstetrics and Gynecology, Beijing, 100191 China
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing, 100191 China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, 100191 China
| | - Lin Zeng
- Research Centre of Clinical Epidemiology, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, 100191 China
| | - Rui Yang
- Centre for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, No.49 North Huayuan Road, Haidian District, Beijing, 100191 China
- National Clinical Research Centre for Obstetrics and Gynecology, Beijing, 100191 China
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing, 100191 China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, 100191 China
| | - Jie Qiao
- Centre for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, No.49 North Huayuan Road, Haidian District, Beijing, 100191 China
- National Clinical Research Centre for Obstetrics and Gynecology, Beijing, 100191 China
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing, 100191 China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, 100191 China
| | - Rong Li
- Centre for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, No.49 North Huayuan Road, Haidian District, Beijing, 100191 China
- National Clinical Research Centre for Obstetrics and Gynecology, Beijing, 100191 China
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing, 100191 China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, 100191 China
| | - Ernest Hung Yu Ng
- Department of Obstetrics and Gynaecology, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong, Special Administrative Region China
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Dallagiovanna C, Reschini M, Polledri E, Pinna M, Ciaffaglione M, Cuce’ V, Somigliana E, Fustinoni S, Filippi F. Effect of letrozole on follicular fluid steroids concentrations in cancer patients undergoing oocytes cryopreservation. J Assist Reprod Genet 2022; 39:1169-1176. [PMID: 35348950 PMCID: PMC9107531 DOI: 10.1007/s10815-022-02477-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 03/22/2022] [Indexed: 10/18/2022] Open
Abstract
PURPOSE To investigate the impact of letrozole administration on follicular steroid hormones during controlled ovarian hyperstimulation for fertility preservation. METHODS One hundred and nineteen women with cancer undergoing oocytes retrieval for fertility preservation were recruited. All women underwent ovarian hyperstimulation according to a random start protocol. Those with hormone-sensitive tumors also received letrozole, an aromatase inhibitor aimed at keeping peripheral estrogen levels low. At the time of oocytes retrieval, a sample of follicular fluid was collected and frozen. All samples were assayed concomitantly after thawing, by liquid chromatography tandem mass spectrometry. The concentration of 15 steroid hormones was determined and results were compared between women who did and did not receive letrozole. RESULTS Fifty-two women were treated with letrozole, while 67 were not. Statistically significant differences emerged for 12 of the 15 tested steroids. They were the following: cortisol, 11-deoxycortisol, 21-deoxycortisol, dehydroepiandrosterone sulfate (DHEAS), dehydroepiandrosterone (DHEA), estradiol, androstenedione, testosterone, dihydrotestosterone (DHT), 17-hydroxyprogesterone, progesterone and corticosterone. The most striking differences were observed for testosterone that showed a more than 200-time increase in women receiving letrozole. Estradiol was conversely reduced to a third. CONCLUSIONS The endocrine microenvironment surrounding oocytes is markedly perturbed by the concomitant assumption of letrozole. Robust clinical evaluation is pressingly needed to rule out any detrimental effect on the chance of live birth with the use of these oocytes.
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12
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The novel incorporation of aromatase inhibitor in hormonal replacement therapy cycles: A randomized clinical trial. Reprod Biomed Online 2021; 44:641-649. [DOI: 10.1016/j.rbmo.2021.10.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/13/2021] [Accepted: 10/22/2021] [Indexed: 11/16/2022]
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13
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Bülow NS, Holt MD, Skouby SO, Petersen KB, Englund ALM, Pinborg A, Macklon NS. Co-treatment with letrozole during ovarian stimulation for IVF/ICSI: a systematic review and meta-analysis. Reprod Biomed Online 2021; 44:717-736. [DOI: 10.1016/j.rbmo.2021.12.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/29/2021] [Accepted: 12/03/2021] [Indexed: 12/20/2022]
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14
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Bülow NS, Skouby SO, Warzecha AK, Udengaard H, Andersen CY, Holt MD, Grøndahl ML, Nyboe Andersen A, Sopa N, Mikkelsen ALE, Pinborg A, Macklon NS. Impact of letrozole co-treatment during ovarian stimulation with gonadotrophins for IVF: a multicentre, randomized, double-blinded placebo-controlled trial. Hum Reprod 2021; 37:309-321. [PMID: 34792133 DOI: 10.1093/humrep/deab249] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 10/20/2021] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTION Does letrozole co-treatment during ovarian stimulation with gonadotrophins for IVF reduce the proportion of women with premature progesterone levels above 1.5 ng/ml at the time of triggering final oocyte maturation? SUMMARY ANSWER The proportion of women with premature progesterone above 1.5 ng/ml was not significantly affected by letrozole co-treatment. WHAT IS KNOWN ALREADY IVF creates multiple follicles with supraphysiological levels of sex steroids interrupting the endocrine milieu and affects the window of implantation. Letrozole is an effective aromatase inhibitor, normalizing serum oestradiol, thereby ameliorating some of the detrimental effects of IVF treatment. STUDY DESIGN, SIZE, DURATION A randomized, double-blinded placebo-controlled trial investigated letrozole intervention during stimulation for IVF with FSH. The trial was conducted at four fertility clinics at University Hospitals in Denmark from August 2016 to November 2018. PARTICIPANTS/MATERIALS, SETTING, METHODS A cohort of 129 women with expected normal ovarian reserve (anti-Müllerian hormone 8-32 nmol/l) completed an IVF cycle with fresh embryo transfer and received co-treatment with either 5 mg/day letrozole (n = 67) or placebo (n = 62), along with the FSH. Progesterone, oestradiol, FSH, LH and androgens were analysed in repeated serum samples collected from the start of the stimulation to the mid-luteal phase. In addition, the effect of letrozole on reproductive outcomes, total FSH consumption and adverse events were assessed. MAIN RESULTS AND THE ROLE OF CHANCE The proportion of women with premature progesterone >1.5 ng/ml was similar (6% vs 0% (OR 0.0, 95% CI [0.0; 1.6], P = 0.12) in the letrozole versus placebo groups, respectively), whereas the proportion of women with mid-luteal progesterone >30 ng/ml was significantly increased in the letrozole group: (59% vs 31% (OR 3.3, 95% CI [1.4; 7.1], P = 0.005)). Letrozole versus placebo decreased oestradiol levels on the ovulation trigger day by 68% (95% CI [60%; 75%], P < 0.0001). Other hormonal profiles, measured as AUC, showed the following results. The increase in LH in the letrozole group versus placebo group was 38% (95% CI [21%; 58%], P < 0.0001) and 34% (95% CI [11%; 61%], P = 0.006) in the follicular and luteal phases, respectively. In the letrozole group versus placebo group, testosterone increased by 79% (95% CI [55%; 105%], P < 0.0001) and 49% (95% CI [30%; 72%], P < 0.0001) in the follicular and luteal phases, respectively. In the letrozole group versus placebo group, the increase in androstenedione was by 85% (95% CI [59%; 114%], P < 0.0001) and 69% (95% CI [48%; 94%], P < 0.0001) in the follicular and luteal phases, respectively. The ongoing pregnancy rate was similar between the letrozole and placebo groups (31% vs 39% (risk-difference of 8%, 95% CI [-25%; 11%], P = 0.55)). No serious adverse reactions were recorded in either group. The total duration of exogenous FSH stimulation was 1 day shorter in the intervention group, significantly reducing total FSH consumption (mean difference -100 IU, 95% CI [-192; -21], P = 0.03). LIMITATIONS, REASONS FOR CAUTION Late follicular progesterone samples were collected on the day before and day of ovulation triggering for patient logistic considerations, and the recently emerged knowledge about diurnal variation of progesterone was not taken into account. The study was powered to detect hormonal variations but not differences in pregnancy outcomes. WIDER IMPLICATIONS OF THE FINDINGS Although the use of letrozole has no effect on the primary outcome, the number of women with a premature increase in progesterone on the day of ovulation triggering, the increased progesterone in the mid-luteal phase due to letrozole may contribute to optimizing the luteal phase endocrinology. The effect of letrozole on increasing androgens and reducing FSH consumption may be used in poor responders. However, the effect of letrozole on implantation and ongoing pregnancy rates should be evaluated in a meta-analysis or larger randomized controlled trial (RCT). STUDY FUNDING/COMPETING INTEREST(S) Funding was received from EU Interreg for ReproUnion and Ferring Pharmaceuticals, and Roche Diagnostics contributed with assays. N.S.M. and A.P. have received grants from Ferring, Merck Serono, Anecova and Gedeon Richter, and/or personal fees from IBSA, Vivoplex, ArtPred and SPD, outside the submitted work. The remaining authors have no competing interests. TRIAL REGISTRATION NUMBERS NCT02939898 and NCT02946684. TRIAL REGISTRATION DATE 15 August 2016. DATE OF FIRST PATIENT’S ENROLMENT 22 August 2016.
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Affiliation(s)
- Nathalie Søderhamn Bülow
- Department of Obstetrics and Gynaecology, Endocrinological and Reproductive Unit, Copenhagen University Hospital, Herlev Hospital, Herlev, Copenhagen, Denmark.,The Fertility Department, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sven Olaf Skouby
- Department of Obstetrics and Gynaecology, Endocrinological and Reproductive Unit, Copenhagen University Hospital, Herlev Hospital, Herlev, Copenhagen, Denmark
| | - Agnieszka Katarzyna Warzecha
- Department of Obstetrics and Gynaecology, Endocrinological and Reproductive Unit, Copenhagen University Hospital, Herlev Hospital, Herlev, Copenhagen, Denmark
| | - Hanne Udengaard
- Department of Obstetrics and Gynaecology, Endocrinological and Reproductive Unit, Copenhagen University Hospital, Herlev Hospital, Herlev, Copenhagen, Denmark
| | - Claus Yding Andersen
- Laboratory of Reproductive Biology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marianne Dreyer Holt
- Department of Obstetrics and Gynaecology, The Fertility Clinic, Zealand University Hospital, Køge, Denmark
| | - Marie Louise Grøndahl
- Department of Obstetrics and Gynaecology, Endocrinological and Reproductive Unit, Copenhagen University Hospital, Herlev Hospital, Herlev, Copenhagen, Denmark
| | | | - Negjyp Sopa
- Department of Obstetrics and Gynaecology, The Fertility Clinic, Copenhagen University Hospital, Hvidovre, Denmark
| | - Anne Lis Englund Mikkelsen
- Department of Obstetrics and Gynaecology, The Fertility Clinic, Zealand University Hospital, Køge, Denmark
| | - Anja Pinborg
- The Fertility Department, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Obstetrics and Gynaecology, The Fertility Clinic, Copenhagen University Hospital, Hvidovre, Denmark
| | - Nicholas Stephen Macklon
- Department of Obstetrics and Gynaecology, The Fertility Clinic, Zealand University Hospital, Køge, Denmark.,London Women's Clinic, London, UK
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Concomitant tamoxifen or letrozole for optimal oocyte yield during fertility preservation for breast cancer: the TAmoxifen or Letrozole in Estrogen Sensitive tumors (TALES) randomized clinical trial. J Assist Reprod Genet 2021; 38:2455-2463. [PMID: 34312774 DOI: 10.1007/s10815-021-02273-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 06/29/2021] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To determine whether concomitant tamoxifen 20 mg with gonadotropins (tamoxifen-gonadotropin) versus letrozole 5 mg with gonadotropins (letrozole-gonadotropin) affects mature oocyte yield. METHODS Open-label, single-institution, randomized trial. Inclusion criteria included the following: females, ages 18-44 years old, with new diagnosis of non-metastatic breast cancer, who were undergoing fertility preservation with either oocyte or embryo cryopreservation. Those with estrogen-receptor-positive (ER+) breast cancer were randomized to tamoxifen-gonadotropin or letrozole-gonadotropin. Another group with estrogen-receptor-negative (ER-) breast cancer was recruited, as a prospectively collected comparison arm who took neither letrozole nor tamoxifen (gonadotropin only). The primary outcome was the number of mature oocytes obtained from the cycle. The randomized groups were powered to detect a difference of three or more mature oocytes. RESULTS Forty-five patients were randomized to tamoxifen-gonadotropin and fifty-one to letrozole-gonadotropin. Thirty-eight patients completed gonadotropin only. Age, antral follicle count, and body mass index were similar between the randomized groups. Our primary outcome of mature oocyte yield was similar between the tamoxifen-gonadotropin and letrozole-gonadotropin groups (12±8.6 vs. 11.6±7.5, p=0.81, 95%CI of difference =-2.9 to 3.7). In a pre-specified secondary comparison, mature oocyte yield was also similar with tamoxifen-gonadotropin or letrozole-gonadotropin versus gonadotropin only (12±8.6 vs. 11.6±7.5 vs. 12.4±7.2). There were no serious adverse events in any of the groups. CONCLUSIONS Tamoxifen-gonadotropin and letrozole-gonadotropin produced a similar number of mature oocytes. Women who received either tamoxifen-gonadotropin or letrozole-gonadotropin had a similar number of oocytes to the gonadotropin-only group. TRIAL REGISTRATION NCT03011684 (retrospectively registered 1/5/2017, after 9% enrolled).
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Khojah M, Khayat S, Dahan MH. Comparison of in vitro fertilization cycles stimulated with 20 mg letrozole daily versus high-dose gonadotropins in Rotterdam Consensus ultra-poor responders: A proof of concept. Int J Gynaecol Obstet 2021; 156:102-106. [PMID: 33507538 DOI: 10.1002/ijgo.13626] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 01/25/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate if high-dose letrozole can be used successfully to stimulate poor responders for in vitro fertilization (IVF). METHODS This was a retrospective study conducted at a university hospital reproductive center. The analysis included women who were up to 42 years of age and were Rotterdam Consensus poor responders. A total of 247 patients received gonadotropins (300-450 IU daily) and 62 patients were stimulated with letrozole (20 mg daily) as part of an antagonist IVF protocol. RESULTS The use of 20 mg of letrozole decreased the total dose of gonadotropins used (645 ± 175 IU vs. 5360 ± 1028 IU, P = 0.001) and resulted in lower costs of stimulation medications ($ 555.56 ± $ 150 vs. $ 4616 ± $ 885 Canadian Dollars; P = 0.001). Pregnancy per cycle (14.5%) and per transfer (16%) rates were legitimate for this low prognosis group and may have been better than or similar to those with high-dose gonadotropins. The rate of cycle cancellation may have been reduced in the letrozole versus gonadotropin group (11% vs. 38%; P = 0.001). CONCLUSION Letrozole (20 mg daily) may be used to reduce the cost of ovarian stimulation in ultra-poor responders, significantly reducing the cost of the IVF cycle with probably at least similar outcomes to high-dose gonadotropins.
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Affiliation(s)
- Mohammad Khojah
- Department of Obstetrics and Gynecology, McGill University, Montreal, QC, Canada.,Division of Reproductive Endocrinology and Infertility, MUHC Reproductive Center, McGill University, Montreal, QC, Canada
| | - Suhaib Khayat
- Department of Obstetrics and Gynecology, McGill University, Montreal, QC, Canada.,Division of Reproductive Endocrinology and Infertility, MUHC Reproductive Center, McGill University, Montreal, QC, Canada
| | - Michael H Dahan
- Department of Obstetrics and Gynecology, McGill University, Montreal, QC, Canada.,Division of Reproductive Endocrinology and Infertility, MUHC Reproductive Center, McGill University, Montreal, QC, Canada
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Bonardi B, Massarotti C, Bruzzone M, Goldrat O, Mangili G, Anserini P, Spinaci S, Arecco L, Del Mastro L, Ceppi M, Demeestere I, Lambertini M. Efficacy and Safety of Controlled Ovarian Stimulation With or Without Letrozole Co-administration for Fertility Preservation: A Systematic Review and Meta-Analysis. Front Oncol 2020; 10:574669. [PMID: 33117711 PMCID: PMC7575927 DOI: 10.3389/fonc.2020.574669] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 09/01/2020] [Indexed: 01/01/2023] Open
Abstract
Background: The co-administration of letrozole during controlled ovarian stimulation (COS) with gonadotropins is used to limit the potentially harmful effects of a supra-physiological rise in estrogen levels on hormone-sensitive cancers. However, the efficacy and safety of adding letrozole to COS remain debated. Methods: This is a systematic review and meta-analysis of published studies that compared the efficacy and safety of COS with co-administration of letrozole vs. COS without letrozole in all patient populations. A secondary analysis was done including only the studies in breast cancer patients. The primary efficacy endpoint was the number of retrieved mature Metaphase II (MII) oocytes. Secondary efficacy and safety endpoints were total number of oocytes, maturation rate, fertilization rate, number of cryopreserved embryos, peak estradiol levels, progesterone levels, and total gonadotropin dose. Data for each endpoint were reported and analyzed thorough mean ratio (MR) with 95% confidence interval (CI). Results: A total of 11 records were selected including 2,121 patients (990 patients underwent COS with letrozole and 1,131 COS without letrozole). The addition of letrozole to COS did not have any negative effect on the number of mature oocytes collected (MR = 1.00, 95% CI = 0.87–1.16; P = 0.967) and the other efficacy endpoints. COS with letrozole was associated with significantly decreased peak estradiol levels (MR = 0.28, 95% CI = 0.24–0.32; P < 0.001). Similar results were observed in the secondary analysis including only breast cancer patients. Conclusions: These findings are reassuring on the efficacy and safety of COS with gonadotropins and letrozole and are particularly important for fertility preservation in women with hormone-sensitive cancers.
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Affiliation(s)
- Benedetta Bonardi
- Research Laboratory on Human Reproduction, Université Libre de Bruxelles (ULB), Brussels, Belgium.,Obstetrics and Gynecology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Claudia Massarotti
- Physiopathology of Human Reproduction Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Marco Bruzzone
- Clinical Epidemiology Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | | | - Giorgia Mangili
- Obstetrics and Gynecology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paola Anserini
- Physiopathology of Human Reproduction Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Stefano Spinaci
- Division of Breast Surgery, Ospedale Villa Scassi, Genova, Italy
| | - Luca Arecco
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy.,Department of Medical Oncology, U.O.C. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Lucia Del Mastro
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy.,Breast Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Marcello Ceppi
- Clinical Epidemiology Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Isabelle Demeestere
- Research Laboratory on Human Reproduction, Université Libre de Bruxelles (ULB), Brussels, Belgium.,Fertility Clinic, CUB-Hôpital Erasme, Brussels, Belgium
| | - Matteo Lambertini
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy.,Department of Medical Oncology, U.O.C. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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18
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Piedimonte S, Volodarsky-Perel A, Tannus S, Tan SL, Dahan MH. Pretreatment with a gonadotropin-releasing hormone agonist and an aromatase inhibitor may improve outcomes in in vitro fertilization cycles of women with stage I-II endometriosis. F&S SCIENCE 2020; 1:98-103. [PMID: 35559744 DOI: 10.1016/j.xfss.2020.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/11/2020] [Accepted: 06/26/2020] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To determine whether 2 months of pretreatment with 5 mg of letrozole daily plus leuprolide acetate at 3.75 mg monthly in women with laparoscopically confirmed American Society of Reproductive Medicine stage I-II endometriosis improves in vitro fertilization (IVF) outcomes. DESIGN Prospective cohort study. SETTING University-affiliated tertiary hospital. PATIENT(S) Women with laparoscopically confirmed endometriosis treated in the period from 2012 to 2016. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Primary outcomes: clinical pregnancy and live-birth rate; secondary outcomes: stimulation parameters and pregnancy. RESULT(S) A total of 68 patients were included in the final analysis. Thirty-six women received a gonadotropin-releasing hormone (GnRH) agonist and an aromatase inhibitor (AI), and 32 women received a GnRH agonist alone. The women did not differ in mean age, antral follicle count, basal serum level of follicle-stimulating hormone, or previous pregnancies. The stimulation parameters were similar between both groups: gonadotropin dose, number of collected oocytes, number of blastocysts. All women underwent a single blastocyst transfer. The grade of embryos transferred did not differ. Clinical pregnancy (24 [66.7%] vs. 13 [40.6%]) and live-birth (22 [61.1%] vs 10 [31.3%]) rates improved with aromatase inhibitor added to the GnRH agonist treatment versus a GnRH agonist alone. CONCLUSION(S) In this study, we present the first comparison in the medical literature comparing IVF outcomes in women with minimal and mild endometriosis pretreated with a GnRH agonist with or without an AI. This prospective cohort study suggests that combining these two treatment modalities which work at different sites may improve pregnancy outcomes with IVF treatment.
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Affiliation(s)
- Sabrina Piedimonte
- Department of Reproductive Endocrinology and Infertility, McGill University, Montreal, Quebec, Canada
| | | | - Samer Tannus
- Department of Reproductive Endocrinology and Infertility, McGill University, Montreal, Quebec, Canada
| | - Seang Lin Tan
- Department of Reproductive Endocrinology and Infertility, McGill University, Montreal, Quebec, Canada
| | - Michael H Dahan
- Department of Reproductive Endocrinology and Infertility, McGill University, Montreal, Quebec, Canada
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19
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A review of the physiology behind letrozole applications in infertility: are current protocols optimal? J Assist Reprod Genet 2020; 37:2093-2104. [PMID: 32712844 PMCID: PMC7492298 DOI: 10.1007/s10815-020-01892-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 07/13/2020] [Indexed: 11/23/2022] Open
Abstract
Letrozole is a targeted aromatase inhibitor which has primarily been used in post-menopausal women with breast cancer. Recently, it has been utilized in infertile pre-menopausal women because of its ability to enhance FSH production for ovulation induction. However, the ovarian follicle’s response to FSH is only a part of the endocrine events occurring in a developing follicle. The health of the small antral follicles is driven primarily by androgens, which contribute to granulosa cell mitosis, sensitivity to FSH, and resistance to atresia. In contrast, elevated androgens in the late antral to pre-ovulatory follicle have a negative impact on follicle health and lead to atresia and cystic follicle formation. This ovarian physiologic data suggests that current applications of letrozole to infertility may be squandering some of the primary benefits available in using letrozole to promote follicle development. Four applications of letrozole to infertility that have appeared in the medical literature are reviewed. Androgen-related benefits are reviewed and various questions put forward about how letrozole could be more effectively used to help patients in these settings.
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20
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Zwiefelhofer EM, Mapletoft RJ, Adams GP. An attempt to potentiate the ovarian superstimulatory response in cattle by co-treatment with an aromatase inhibitor. Theriogenology 2020; 157:1-6. [PMID: 32768722 DOI: 10.1016/j.theriogenology.2020.07.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/09/2020] [Accepted: 07/16/2020] [Indexed: 11/16/2022]
Abstract
Letrozole is used for the treatment of subfertility in women undergoing ovarian superstimulation, but the mechanism of action has not been investigated critically. The objective was to test the hypothesis that treatment with letrozole will potentiate the superstimulatory response following gonadotropin treatment by increasing the number of follicles present at ovarian follicular wave emergence in cattle. In Experiment 1, ovarian follicular wave emergence was synchronized among beef heifers (n = 8) by transvaginal ultrasound-guided follicle ablation. On Day 0 (wave emergence), a letrozole-releasing device (LRD) was placed intravaginally for 5 days, followed again by transvaginal follicle ablation on Day 5. The number of follicles ≥3 mm was recorded by transrectal ultrasonography on Days 0 and 6.5 (i.e., pre- vs. post-LRD treatment). In Experiment 2, non-lactating dairy cows were assigned randomly to one of two groups (n = 15/gp) after follicle ablation-induced synchronization of wave emergence (Day 0), and given either an LRD or sham device for 5 days. Superstimulatory treatment was initiated on Day 0, consisting of 8 doses of 50 mg of porcine FSH im at 12 h intervals, and luteolytic doses of prostaglandin on Days 3 and 3.5. The LRD/sham devices were removed on Day 3.5, GnRH was given im on Day 5, estrus response was determined on Days 5 and 6, and the ovarian response was recorded by ultrasonography on Days 0, 3.5, 5, 6.5, and 12. In Experiment 1, no difference was detected in the number of antral follicles at wave emergence pre- vs. post-LRD treatment (23.2 ± 3.2 vs. 23.5 ± 3.8 follicles; P = 0.67; mean ± SEM). In Experiment 2, the interval from prostaglandin treatment to estrus was longer (50.3 ± 1.1 vs. 40.7 ± 2.0 h; P < 0.001) and less variable (residuals: 3.1 ± 0.5 vs. 6.7 ± 0.9 h; P < 0.01) in the LRD vs. sham group. The proportion of ovulations (number of CL on Day 12 over the number of follicles ≥3 mm on Day 0) did not differ (0.65 ± 0.02 vs. 0.70 ± 0.02; P = 0.15) nor did the number of CL on Day 12 (15.9 ± 2.5 vs. 19.0 ± 2.0; P = 0.32) between the LRD and sham groups. In summary, treatment with letrozole did not increase the number of antral follicles at wave emergence or the superstimulatory response, but increased precision in the interval to estrus and may be useful for artificial insemination at a fixed time in superstimulatory protocols.
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Affiliation(s)
- Eric M Zwiefelhofer
- Department of Veterinary Biomedical Sciences, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Reuben J Mapletoft
- Department of Large Animal Clinical Sciences, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Gregg P Adams
- Department of Veterinary Biomedical Sciences, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
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21
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Shapira M, Orvieto R, Lebovitz O, Nahum R, Aizer A, Segev-Zahav A, Haas J. Does daily co administration of gonadotropins and letrozole during the ovarian stimulation improve IVF outcome for poor and sub optimal responders? J Ovarian Res 2020; 13:66. [PMID: 32513279 PMCID: PMC7282086 DOI: 10.1186/s13048-020-00666-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/25/2020] [Indexed: 12/02/2022] Open
Abstract
Background Co-administration of letrozole during the first 5 days of ovarian stimulation was suggested to improve IVF outcomes in poor responders. We aimed to determine whether poor/sub-optimal responders might benefit from Letrozole co-treatment throughout the entire stimulation course. Methods We retrospectively reviewed the medical files of women who demonstrated poor (oocyte yield ≤3) and sub-optimal (4 ≤ oocyte yield ≤9) ovarian response during conventional multiple-dose antagonist stimulation protocols and were co-treated in a subsequent cycle with 5 mg Letrozole from the first day of stimulation until trigger day. A self-paired comparison between gonadotropins-only and gonadotropins-letrozole cycles was performed. Results Twenty-four patients were included. Mean patients’ age was 39.83 ± 4.60 and mean day-3-FSH was 12.77 ± 4.49 IU/m. Duration of stimulation and total gonadotropins dose were comparable between the two cycle groups. Peak estradiol levels were significantly lower in gonadotropins-letrozole cycles (2786.74 ± 2118.53 vs 1200.13 ± 535.98, p < 0.05). Number of retrieved oocytes (3.29 ± 2.15 vs 6.46 ± 3.20, p < 0.05), MII-oocytes (2.47 ± 1.65 vs 5.59 ± 3.20, p < 0.05), 2PN-embryos (1.78 ± 1.50, 4.04 ± 2.74, p < 0.05) and top-quality embryos (0.91 ± 0.97 vs. 2.35 ± 1.66, p < 0.05) were significantly higher in the gonadotropins-letrozole cycles. Clinical pregnancy rate in gonadotropins-letrozole cycles was 31.5%. Conclusion Letrozole co-treatment during the entire stimulation course improves ovarian response and IVF outcomes in poor/sub-optimal responders.
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Affiliation(s)
- Moran Shapira
- IVF unit, Division of Obstetrics and Gynecology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Raoul Orvieto
- IVF unit, Division of Obstetrics and Gynecology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Oshrit Lebovitz
- IVF unit, Division of Obstetrics and Gynecology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ravit Nahum
- IVF unit, Division of Obstetrics and Gynecology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Adva Aizer
- IVF unit, Division of Obstetrics and Gynecology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Aliza Segev-Zahav
- IVF unit, Division of Obstetrics and Gynecology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Jigal Haas
- IVF unit, Division of Obstetrics and Gynecology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
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22
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Eftekhar M, Saeed L. Effect of adding letrozole to gonadotropin on in vitro fertilization outcomes: An RCT. Int J Reprod Biomed 2020; 18:287-294. [PMID: 32494767 PMCID: PMC7218674 DOI: 10.18502/ijrm.v13i4.6891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 10/23/2019] [Accepted: 11/27/2019] [Indexed: 11/24/2022] Open
Abstract
Background Aromatase inhibitors prevent the aromatization of androgens into estrogens, which reduces the negative feedback of estrogen on the hypothalamic-pituitary axis. It is clear that increasing the secretion of follicle-stimulating hormones results in an increased follicular growth. Objective This study aimed to evaluate the effect of adding letrozole to gonadotropin on in vitro fertilization outcomes in normal responders. Materials and Methods In this randomized clinical trial, 100 normal responder women candidate for controlled ovarian stimulation were randomly enrolled in two groups (n = 50/each). In the case group letrozole was added to gonadotropin in the antagonist protocol. The control group received the conventional antagonist protocol. The main outcome was clinical and chemical pregnancy; and the second outcomes were the number of mature oocytes, the fertilization rate, estradiol level, and the total dose of gonadotropins. Results Basic clinical and demographic features were comparable between the groups. Estradiol level on the day of human-chorionic-gonadotropin administration and the total gonadotropin consumption were significantly higher in the control group than the case group (p = 0.045). In addition, the number of MII oocytes was higher (but not significantl) in the case group than the control group (p = 0.09). Moreover, the endometrial thickness was significantly lower in the case group. There were no significant differences in fertilization rate and chemical and clinical pregnancy rates between the two groups. Conclusion Although adding letrozole to gonadotropin in normal responders reduces the total dose of gonadotropin, it does not improve the pregnancy outcomes.
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Affiliation(s)
- Maryam Eftekhar
- Research and Clinical Center for Infertility, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Lida Saeed
- Afzalipour Hospital, Kerman University of Medical Science, Kerman, Iran
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23
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Tshzmachyan R, Hambartsoumian E. The role of Letrozole (LE) in controlled ovarian stimulation (COS) in patients at high risk to develop ovarian hyper stimulation syndrome (OHSS). A prospective randomized controlled pilot study. J Gynecol Obstet Hum Reprod 2019; 49:101643. [PMID: 31563697 DOI: 10.1016/j.jogoh.2019.101643] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 06/30/2019] [Accepted: 09/25/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Recently, it has been shown that PCOS patients with extremely high anti-Mullerian hormone (AMH) level are more likely to experience OHSS during IVF, compared to PCOS patients with lower AMH level. While recent data questioned the effect of Letrozole (LE) on the occurrence of OHSS in non-PCOS patients, it role in PCOS patients with very high AMH level was never investigated in a prospective manners. Hence, our main objective was to evaluate the clinical outcome of PCOS patients at very high risk for OHSS undergoing two different COS protocols (with or without LE). METHODS A prospective randomized controlled study (RCT) of 51 patients with specifically high levels of AMH undergoing one of two COS protocols. The control group (group A) consisted of 24 PCOS women who received low-dose gonadotropins using the multiple-dose GnRH-antagonist protocol, GnRH agonist-triggered and "freeze all". The study group (group B) consisted of 24 women with PCOS who received the same protocol combined with LE. High risk criteria for OHSS were: PCOS patients with low BMI, young age, and extremely high level of serum AMH (inclusion criteria for AMH > 50 pmol/L). RESULTS Cumulative live birth rates per retrieval were similar in both groups. While no single case of severe OHSS was observed in, in the study group (group B), the rate of moderate and mild OHSS was 5 times lower compared to the control group (P < 0.05). CONCLUSION In PCOS patients with extremely high AMH levels the LE co-administration to GnRH-Ant protocols results in reduced incidence of OHSS than conventional GnRH-Ant protocols. LE co-administration may prove to be highly effective in preventing OHSS, even in the women who are at high risk to these dangerous complications.
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Affiliation(s)
- Ruzanna Tshzmachyan
- Fertility Center, Yerevan State Medical University, 41/7 Moldovakan street, Nor Nork, 0062, Yerevan, Armenia.
| | - Eduard Hambartsoumian
- Fertility Center, Yerevan State Medical University, 41/7 Moldovakan street, Nor Nork, 0062, Yerevan, Armenia.
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24
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Cantor A, Tannus S, Son WY, Tan SL, Dahan MH. A comparison of two months pretreatment with GnRH agonists with or without an aromatase inhibitor in women with ultrasound-diagnosed ovarian endometriomas undergoing IVF. Reprod Biomed Online 2019; 38:520-527. [DOI: 10.1016/j.rbmo.2018.12.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 10/07/2018] [Accepted: 12/10/2018] [Indexed: 01/01/2023]
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25
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Ben-Haroush A, Wertheimer A, Klochendler E, Sapir O, Shufaro Y, Oron G. Effect of letrozole added to gonadotropins in controlled ovarian stimulation protocols on the yield and maturity of retrieved oocytes. Gynecol Endocrinol 2019; 35:324-327. [PMID: 30596311 DOI: 10.1080/09513590.2018.1534950] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
We aimed to evaluate the effect of co-administration of letrozole and gonadotropins during ovarian stimulation on oocyte yield and maturation in breast cancer patients prior to chemotherapy. A retrospective cohort design was used comparing oocyte cryopreservation cycles among patients with breast cancer patients with other oncological indications and women undergoing elective oocyte cryopreservation. All patients were treated with GnRH antagonist protocol using GnRH agonist for final oocyte maturation. The breast cancer group was additionally treated with letrozole (5 mg/d) from the first day of treatment until the day of oocyte retrieval. The cohort included 418 patients: 145 breast cancer patients, 168 with other oncological indications, and 105 patients who chose to undergo elective oocyte cryopreservation. There were no significant differences among the groups in the number of retrieved oocytes or proportion of mature oocytes. On multivariate linear regression models, co-treatment with letrozole was not a significant factor for the number of retrieved oocytes or for oocyte maturation rate after controlling for age, body mass index (BMI), and FSH dose. We conclude that the addition of letrozole to gonadotropins does not increase the number of oocytes retrieved or the oocyte maturation rate.
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Affiliation(s)
- Avi Ben-Haroush
- a IVF and Infertility Unit , Helen Schneider Hospital for Women, Rabin Medical Center, Beilinson Hospital , Petach Tikva , Israel
- b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Avital Wertheimer
- a IVF and Infertility Unit , Helen Schneider Hospital for Women, Rabin Medical Center, Beilinson Hospital , Petach Tikva , Israel
- b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Emilie Klochendler
- a IVF and Infertility Unit , Helen Schneider Hospital for Women, Rabin Medical Center, Beilinson Hospital , Petach Tikva , Israel
- b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Onit Sapir
- a IVF and Infertility Unit , Helen Schneider Hospital for Women, Rabin Medical Center, Beilinson Hospital , Petach Tikva , Israel
- b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Yoel Shufaro
- a IVF and Infertility Unit , Helen Schneider Hospital for Women, Rabin Medical Center, Beilinson Hospital , Petach Tikva , Israel
- b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Galia Oron
- a IVF and Infertility Unit , Helen Schneider Hospital for Women, Rabin Medical Center, Beilinson Hospital , Petach Tikva , Israel
- b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
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26
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Goldrat O, Van Den Steen G, Gonzalez-Merino E, Dechène J, Gervy C, Delbaere A, Devreker F, De Maertelaer V, Demeestere I. Letrozole-associated controlled ovarian hyperstimulation in breast cancer patients versus conventional controlled ovarian hyperstimulation in infertile patients: assessment of oocyte quality related biomarkers. Reprod Biol Endocrinol 2019; 17:3. [PMID: 30606204 PMCID: PMC6318989 DOI: 10.1186/s12958-018-0443-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 12/12/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fertility preservation (FP) protocols in case of breast cancer (BC) include mature oocyte cryopreservation following letrozole associated controlled ovarian hyperstimulation (Let-COH). To date, the impact of Let-COH on the follicular microenvironment has been poorly investigated, although a high androgen/estrogen ratio was previously associated with low oocyte quality. METHODS In this prospective study, follicular fluid (FF) steroid levels (estradiol, testosterone, progesterone) and cumulus cell (CC) gene expression related to oocyte quality (HAS2, PTGS2, GREM1) were compared between 23 BC patients undergoing Let-COH for FP and 24 infertile patients undergoing conventional COH without letrozole. All patients underwent an antagonist COH cycle, and ovulation was triggered with hCG or GnRHa in both groups. RESULTS FF estradiol levels were significantly lower while testosterone levels were significantly higher in the study group compared to controls irrespective of the trigger method. However, estradiol levels increased significantly with GnRHa triggering compared to hCG in the study group (median = 194.5 (95.4-438) vs 64.4 (43.8-152.4) ng/ml, respectively, p < 0.001), but not in the control group (median = 335.5 (177.5-466.7) vs 354 (179-511) ng/ml, respectively). After hCG trigger, Cumulus cell (CC) gene expression was lower in the study group compared to the control group, and difference was significant for PTGS2. Conversely, CC gene expression of PTGS2 and GREM1 was significantly higher in the study group compared to controls when ovulation was triggered with GnRHa. CONCLUSIONS Let-COH triggered with hCG may negatively impact oocyte quality. However, ovulation triggering with GnRHa may improve the oocyte microenvironment and cumulus cell genes expression in Let-COH, suggesting a positive impact on oocyte quality in breast cancer patients. TRIAL REGISTRATION Clinicaltrials.gov - NCT02661932 , registered 25 January 2016, retrospectively registered.
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Affiliation(s)
- Oranite Goldrat
- Fertility Clinic, Department of Obstetrics and Gynecology, CUB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik 808, Brussels, Belgium.
- Research Laboratory on Human Reproduction, Université Libre de Bruxelles (ULB), Route de Lennik 808, Brussels, Belgium.
| | - Geraldine Van Den Steen
- Research Laboratory on Human Reproduction, Université Libre de Bruxelles (ULB), Route de Lennik 808, Brussels, Belgium
| | - Eric Gonzalez-Merino
- Fertility Clinic, Department of Obstetrics and Gynecology, CUB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik 808, Brussels, Belgium
| | - Julie Dechène
- Research Laboratory on Human Reproduction, Université Libre de Bruxelles (ULB), Route de Lennik 808, Brussels, Belgium
| | - Christine Gervy
- Laboratory of Chemistry, CUB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik 808, Brussels, Belgium
| | - Anne Delbaere
- Fertility Clinic, Department of Obstetrics and Gynecology, CUB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik 808, Brussels, Belgium
| | - Fabienne Devreker
- Fertility Clinic, Department of Obstetrics and Gynecology, CUB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik 808, Brussels, Belgium
| | - Viviane De Maertelaer
- IRIBHM and SBIM, Université Libre de Bruxelles (ULB), Route de Lennik 808, Brussels, Belgium
| | - Isabelle Demeestere
- Fertility Clinic, Department of Obstetrics and Gynecology, CUB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik 808, Brussels, Belgium
- Research Laboratory on Human Reproduction, Université Libre de Bruxelles (ULB), Route de Lennik 808, Brussels, Belgium
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27
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Chen Y, Yang T, Hao C, Zhao J. A Retrospective Study of Letrozole Treatment Prior to Human Chorionic Gonadotropin in Women with Polycystic Ovary Syndrome Undergoing In Vitro Fertilization at Risk of Ovarian Hyperstimulation Syndrome. Med Sci Monit 2018; 24:4248-4253. [PMID: 29925074 PMCID: PMC6042308 DOI: 10.12659/msm.910743] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Background Women with polycystic ovary syndrome (PCOS) undergoing in vitro fertilization (IVF) are given letrozole before a trigger injection of human chorionic gonadotropin (hCG) to lower estrogen (E2) levels, but can experience ovarian hyperstimulation syndrome (OHSS). The aim of this study was to evaluate the effect of oral letrozole, prior to administration of hCG, on the outcome of IVF and development of OHSS. Material/Methods Retrospective clinical review included 181 cases of women with PCOS who underwent IVF cycles with intracytoplasmic sperm injection (ICSI) and embryo transfer (ET) (IVF/ICSI-ET). The day before the use of hCG, cases were divided into a letrozole-treated group (N=78) and a non-letrozole group (N=103). An oral dose of 2.5 mg qd of letrozole was given when the peak level of E2 was ≥4000 pg/ml during ovarian stimulation and ceased before the day of egg retrieval. Results The letrozole-treated group had a significant increase in the number of retrieved oocytes, viable embryos, and fresh ET rate (P>0.05); peak levels of E2, and E2 levels on the day of the egg retrieval, were significantly higher, and the fertilization rate was significantly lower (P<0.001). No significant differences were found in the rates of pregnancy, abortion, or ectopic pregnancy between the two groups (P>0.05). The incidence OHSS was lower in the letrozole-treated group, but this difference did not reach statistical significance (P>0.05). Conclusions Women with PCOS who underwent IVF, oral treatment with letrozole a day prior to treatment with hCG lowered E2 levels, but did not significantly reduce the incidence of OHSS.
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Affiliation(s)
- Yilu Chen
- Shandong University School of Medicine, Shandong, China (mainland).,Reproductive Center, Department of Obstetrics and Gynaecology, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Tanchu Yang
- Reproductive Center, Department of Obstetrics and Gynaecology, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Cuifang Hao
- Shandong University School of Medicine, Shandong, China (mainland).,Department of Assisted Reproduction, Yuhuangding Hospital, Yantai, Shandong, China (mainland)
| | - Junzhao Zhao
- Reproductive Center, Department of Obstetrics and Gynaecology, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
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28
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Haas J, Bassil R, Gonen N, Meriano J, Jurisicova A, Casper RF. The VEGF and PEDF levels in the follicular fluid of patients co- treated with LETROZOLE and gonadotropins during the stimulation cycle. Reprod Biol Endocrinol 2018; 16:54. [PMID: 29843716 PMCID: PMC5975523 DOI: 10.1186/s12958-018-0367-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 05/09/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Previous studies have shown that androgens, in addition to serving as precursors for ovarian estrogen synthesis, also have a fundamental role in primate ovarian follicular development by augmentation of FSH receptor expression on granulosa cells. Recent studies have shown that aromatase inhibitor, letrozole, improves ovarian response to FSH in normal and poor responder patients, possibly by increasing intraovarian androgen levels. Studies in mice also showed an effect of letrozole to increase pigment epithelium-derived factor (PEDF) and to lower vascular epithelial growth factor (VEGF), which might be expected to reduce the risk of ovarian hyperstimulation syndrome (OHSS) with stimulation. The aim of this study was to compare the VEGF and PEDF levels in the follicular fluids of normal responders treated with letrozole and gonadotropins during the ovarian stimulation with patients treated with gonadotropins only. METHODS A single center, prospective clinical trial. We collected follicular fluid from 26 patients, on a GnRH antagonist protocol, dual triggered with hCG and GnRH agonist. The patients in one group were co-treated with letrozole and gonadotropins during the ovarian stimulation and the patients in the other group were treated with gonadotropins only. VEGF, PEDF, estrogen, progesterone and testosterone levels were measured by ELISA kits. RESULTS The age of the patients, the total dose of gonadotropins and the number of oocytes were comparable between the two groups. In the follicular fluid, the estrogen levels (2209 nmol/l vs. 3280 nmol/l, p = 0.02) were significantly decreased, and the testosterone levels (246.5 nmol/l vs. 40.7 nmol/l, p < 0.001) were significantly increased in the letrozole group compared to the gonadotropin only group. The progesterone levels (21.4 μmol/l vs. 17.5 p = NS) were comparable between the two groups. The VEGF levels (2992 pg/ml vs. 1812 pg/ml p = 0.02) were significantly increased and the PEDF levels (9.7 ng/ml vs 17.3 ng/ml p < 0.001) were significantly decreased in the letrozole group. CONCLUSIONS Opposite to observations in the mouse, we found that VEGF levels were increased and PEDF levels were decreased in the follicular fluid in patients treated with letrozole during the stimulation cycles. Further investigation is required to determine if patients treated with letrozole during the IVF stimulation protocol are at increased risk for developing OHSS as a result of these findings.
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Affiliation(s)
- Jigal Haas
- 0000 0001 2157 2938grid.17063.33Division of Reproductive Sciences, University of Toronto, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada
- TRIO fertility partners, 655 Bay St 11th floor, Toronto, ON M5G 2K4 Canada
- 0000 0004 1937 0546grid.12136.37Department of Obstetrics and Gynecology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Hashomer, Israel
| | - Rawad Bassil
- 0000 0001 2157 2938grid.17063.33Division of Reproductive Sciences, University of Toronto, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada
- TRIO fertility partners, 655 Bay St 11th floor, Toronto, ON M5G 2K4 Canada
| | - Noa Gonen
- 0000 0001 2157 2938grid.17063.33Division of Reproductive Sciences, University of Toronto, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada
- TRIO fertility partners, 655 Bay St 11th floor, Toronto, ON M5G 2K4 Canada
| | - Jim Meriano
- 0000 0001 2157 2938grid.17063.33Division of Reproductive Sciences, University of Toronto, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada
- TRIO fertility partners, 655 Bay St 11th floor, Toronto, ON M5G 2K4 Canada
| | - Andrea Jurisicova
- 0000 0001 2157 2938grid.17063.33Division of Reproductive Sciences, University of Toronto, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada
- TRIO fertility partners, 655 Bay St 11th floor, Toronto, ON M5G 2K4 Canada
| | - Robert F. Casper
- 0000 0001 2157 2938grid.17063.33Division of Reproductive Sciences, University of Toronto, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada
- TRIO fertility partners, 655 Bay St 11th floor, Toronto, ON M5G 2K4 Canada
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Yee T, Khalid S, Azrai A, Abdul K, Hashim O. A study on the effectiveness of clomiphene citrate in comparison to GnRH antagonist in preventing LH surge among patients undergoing ovulation induction in IVF-ICSI. SANAMED 2018. [DOI: 10.24125/sanamed.v13i2.241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Abstract: Objective: To determine the efficacy of clomiphene citrate (CC) in preventing luteinizing hormone (LH) surge without adding gonadotropin releasing hormone (GnRH) antagonist or GnRH agonist in stimulated first fresh intracytoplasmic sperm injection cycle by evaluating the outcome of oocytes and embryo quality. Design: Registry cohort study. Settings: Fertility Clinic Registry at Hospital University Kebangsaan Malaysia. Patients: A total of 235 fresh stimulated ICSI cycle for patients aged 18-40 years old using clomiphene citrate plus gonadotropin (n = 117) and GnRH antagonist plus gonadotropin (n = 118) were studied. Intervention: Comparing two different ovarian stimulation protocol. Main outcome measure(s): Social economical demographic, ovarian stimulation response and laboratory outcome. Fertilization rate as our primary outcome and our secondary outcome were oocyte retrieval rate, mature oocyte rate and top quality embryo rate. Result(s):There were no difference in the demographic and hormonal characteristic of the study groups. The primary outcome of fertilization rate has significant difference with p value of 0.003; 73.2% for CC group and 64.2% for GnRH antagonist group. The secondary outcome of OR rate (78.4% ± 17.6% VS 80.3% ± 13.4%, p = 0.368), mature oocyte rate (85.2% ± 19.0 VS 81.7% ± 16.7%, p = 0.130) and top quality embryo rate (79.4% ± 24.2% VS 74.9% ± 22.9%, p = 0.178) were comparable between both groups. There were significant difference between the endometrial thickness on the day of trigger and OHSS risk among both groups (8.5 mm ± 1.0 mm VS 9.4 mm ± 1.1 mm, p < 0.001 and 12.8% VS 44.1% respectively). Discussion: Minimal stimulation protocol with CC and gonadotropin may be the answer to many infertile couples in need of IVF and yet having financial situation deterring them in attempting IVF treatment. GnRH antagonist could be safely replaced by CC by extending to 10 days as this protocol gives better primary outcome and comparable secondary outcomes with less OHSS. CC is recognized to induce thinning of endometrial lining and thus, may impair embryo implantation. However, with advancement of the vitrification system and higher success rate in frozen-thaw embryo transfer worldwide provides an excellent solution for this issue.
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