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Lin J, Wu F, Zhang K, Zhu Y, Wang B, Zhu Q, Lin J. Impact of 2.5 mg versus 5 mg letrozole co-treatment in an antagonist protocol for IVF: a retrospective study. Front Endocrinol (Lausanne) 2023; 14:1289595. [PMID: 38027191 PMCID: PMC10668011 DOI: 10.3389/fendo.2023.1289595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/27/2023] [Indexed: 12/01/2023] Open
Abstract
Objective The present study aimed to compare the effectiveness of two different doses of letrozole (2.5 mg and 5 mg daily) in an antagonist protocol for infertile women with normal ovarian reserve. Methods This retrospective cohort study included infertile women who underwent in vitro fertilization treatment with letrozole co-treatment at doses of 2.5 mg and 5 mg from 2007 - 2021 at Shanghai Ninth People's Hospital (Shanghai, China). The control group comprised infertile women who received gonadotropin-releasing hormone antagonist alone. The primary outcome was the cumulative live birth rate, while secondary outcomes included follicular phase endocrine parameters, ovarian stimulation outcomes, pregnancy outcomes, and the incidences of maternal and neonatal complications. Baseline and follow-up data were compared between the groups using ANOVA for normally distributed variables, the Kruskal-Wallis test for non-normally distributed variables, and the Chi-square test for categorical variables. Results A total of 422 participants were enrolled in the study, with 211 women in the antagonist group, 109 women in the 2.5 mg letrozole co-treatment group, and 102 women in the 5 mg letrozole co-treatment group. Letrozole co-treatment significantly suppressed oestradiol and follicle-stimulating hormone concentrations from stimulation day 5 and onwards, while increasing luteinizing hormone levels on stimulation day 5 and trigger day. The effect was more pronounced with a 5 mg dose of letrozole compared to a 2.5 mg dose (P < 0.05). Administration of 5 mg letrozole reduced the gonadotropin dose (P < 0.05) without negatively affecting the number of oocytes retrieved and subsequent embryo parameters (P > 0.05). The analysis of cumulative live birth rates showed rates of 29.4% in the letrozole 5 mg group, 27.5% in the letrozole 2.5 mg group, and 33.6% in the control group, with no statistically significant difference (P > 0.05). There were no reported pregnancy complications in the two letrozole groups. Additionally, there were no significant differences among the three groups in terms of gestational age and birth weight for both singleton and twin births. Conclusion This study indicates that the administration of letrozole in an antagonist protocol, at both 2.5 mg and 5 mg dosages, results in comparable clinical outcomes.
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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
| | - Kai Zhang
- China National Cancer Center/National Clinical Research Center for Cancer/Hebei Cancer Hospital, Chinese Academy of Medical Sciences, Langfang, 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
| | - Qianqian Zhu
- Department of Assisted Reproduction, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, 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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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: 1] [Impact Index Per Article: 1.0] [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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Zhang S, Gao F, Fu M, Shen H, Wang Y, Han H. Effects of letrozole co-treatment on the cumulative live-birth rate among normal responders in gonadotropin-releasing hormone antagonist cycles. Front Med (Lausanne) 2022; 9:1070583. [PMID: 36569134 PMCID: PMC9772441 DOI: 10.3389/fmed.2022.1070583] [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: 10/15/2022] [Accepted: 11/22/2022] [Indexed: 12/12/2022] Open
Abstract
Studies have shown that letrozole cotreatment can improve clinical outcomes in high and poor responders in GnRH-antagonist protocol. However, whether letrozole is also beneficial to normal responders is not known. To investigate the clinical value of letrozole cotreatment during ovarian stimulation in vitro fertilization for normal ovarian reserve patients who were treated with the GnRH antagonist protocol, we conducted a retrospective study that based data from 1 January to 31 December 2017 for all IVF-ICSI GnRH-antagonist protocols. A total of 252 women who aged <40 years, FSH <10 IU/L on day 3 and antral follicle counting (AFC) >6 were included in the analysis (96 in the letrozole group and 156 in the no-letrozole group). The cumulative live-birth rate was calculated as the first live birth achieved after all cycles having an embryo transfer (cycles using fresh embryos and frozen-thawed embryos) among both groups. The initial gonadotropin (Gn) dosage and total Gn dosage were significantly lower and the number of days of Gn treatment was significantly fewer in the letrozole group than the non-letrozole group (p < 0.05). There were also significant between-group differences in luteinizing hormone, estradiol, and progesterone concentrations; and the number of metaphase II oocytes on the day of human chorionic gonadotropin treatment (p < 0.05). There was a significant difference in the implantation rate between the two groups that the letrozole group higher than the non-letrozole group (39.79 vs. 27.96%, p = 0.006), but there was no significant difference in the cumulative live-birth rate. The combination of letrozole with a GnRH antagonist may have no effect on the clinical pregnancy rate or cumulative live-birth rate in patients with a normal ovarian reserve. However, letrozole may increase the rate of embryo implantation and may reduce the requirement for exogenous gonadotrophins and, consequently, the cost of an IVF treatment cycle. In addition, the decreased estradiol level in the ovarian simulation by letrozole supports letrozole can be a safe solution for fertility preservation in estrogen-related cancer patients.
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Muacevic A, Adler JR, Gopal U, Banait T. A Review on the Use of Letrozole in Female and Male Infertility. Cureus 2022; 14:e31291. [PMID: 36514610 PMCID: PMC9733584 DOI: 10.7759/cureus.31291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 11/09/2022] [Indexed: 11/11/2022] Open
Abstract
Infertility in developing countries is a distinct and complex problem that disproportionately affects women. Though not a physically restraining disease, it causes a huge social burden on the emotional, financial, and psychosocial quotients of those who suffer from it. Assisted reproductive procedures are frequently used to treat infertility. Years ago, the emergence of ovulation induction represented a significant advancement in treating female infertility. Letrozole, an aromatase inhibitor, is a potential therapy for ovulation induction. Numerous clinical conditions, including anovulatory infertility, polycystic ovarian syndrome, unexplained infertility, and early stages of endometriosis-related infertility, as well as many with improved live birth rates, have been proven to benefit from letrozole treatment. Letrozole is a superior alternative to the widely utilized ovulation induction with clomiphene citrate. While clomiphene citrate has certain limitations, letrozole successfully overcomes these limitations because of its lack of prolonged anti-estrogenic activity, short half-life, and lack of estrogen receptor activation. In most cases, this results in mono-follicular development and excellent live birth rates. According to the most recent research, letrozole can be used as the first-line therapy to treat infertility caused by polycystic ovarian syndrome and other causes. Letrozole is also emerging as a possible treatment for male infertility of unknown cause, proving to be an effective way of influencing hormonal profiles and increasing various seminal parameters such as sperm motility and concentration, as it inhibits aromatization affecting the feedback mechanism to the hypothalamus. This review focuses on our current knowledge of the uses of letrozole for female and male infertility, its mechanisms, and its benefits.
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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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Dreyer Holt M, Skouby SO, Bülow NS, Englund ALM, Birch Petersen K, Macklon NS. The Impact of Suppressing Estradiol During Ovarian Stimulation on the Unsupported Luteal Phase: A Randomized Controlled Trial. J Clin Endocrinol Metab 2022; 107:e3633-e3643. [PMID: 35779242 DOI: 10.1210/clinem/dgac409] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Supraphysiological sex steroid levels at the follicular-luteal phase transition are implicated as the primary cause of luteal insufficiency after ovarian stimulation (OS) for in vitro fertilization. OBJECTIVE We aimed to determine the impact of suppressing estradiol levels during OS of multiple dominant follicles on the unsupported luteal phase and markers of endometrial maturation. METHODS At 2 university hospitals, 25 eligible egg donors were randomized to undergo OS using exogenous gonadotropins with or without adjuvant letrozole 5 mg/day. Final oocyte maturation was triggered with a GnRH agonist. No luteal support was provided. The primary outcome was the duration of the luteal phase. Secondary outcomes were luteal phase hormone profiles and the endometrial transcriptomic signature 5 days after oocyte pick up (OPU + 5). RESULTS The median (interquartile range [IQR]) luteal phase duration was 8.0 (6.8-11.5) days compared with 5.0 (5.0-6.8) days in the intervention and control group, respectively (P < 0.001). Estradiol levels were effectively suppressed in the letrozole group with a median of 0.86 (0.23-1.24) nmol/L at OPU compared to 2.82 (1.34-3.44) nmol/L in the control group. Median (IQR) progesterone levels at OPU + 5 were 67.05 (15.67-101.75) nmol/L in the letrozole group vs 2.27 (1.05-10.70) nmol/L in the control group (P < 0.001). In the letrozole group, 75% of participants revealed endometrial transcriptomic signatures interpreted as post-receptive. In the control group, 40% were post-receptive and 50% noninformative. CONCLUSION Suppressing estradiol levels in the follicular phase with adjuvant letrozole significantly reduces the disruption of the unsupported luteal phase after OS.
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Affiliation(s)
- Marianne Dreyer Holt
- Department of Gynecology and Obstetrics, The Fertility Clinic and ReproHealth Consortium, Zealand University Hospital, Lykkebækvej 14, 4600 Køge, Denmark
| | - Sven Olaf Skouby
- Department of Gynecology and Obstetrics, The Fertility Clinic, Herlev University Hospital, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Nathalie Søderhamn Bülow
- Department of Gynecology and Obstetrics, The Fertility Clinic, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Anne Lis Mikkelsen Englund
- Department of Gynecology and Obstetrics, The Fertility Clinic and ReproHealth Consortium, Zealand University Hospital, Lykkebækvej 14, 4600 Køge, Denmark
| | - Kathrine Birch Petersen
- TFP Stork Fertility, The Fertility Partnership, Store Kongensgade 40G 1., 1264 Copenhagen, Denmark
| | - Nicholas Stephen Macklon
- Department of Gynecology and Obstetrics, The Fertility Clinic and ReproHealth Consortium, Zealand University Hospital, Lykkebækvej 14, 4600 Køge, Denmark
- London Women's Clinic, 113-115 Harley Street, London W1G 6AP, UK
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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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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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Liang Y, Guo Q, Wu XH, Zhang LN, Ge J, Xu ML, Feng ZL, Wu XQ. Does the additional use of clomiphene citrate or letrozole for in vitro fertilization deserve more attention? BMC Pregnancy Childbirth 2021; 21:275. [PMID: 33794797 PMCID: PMC8017864 DOI: 10.1186/s12884-021-03668-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 02/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adding clomiphene citrate (CC) and/or letrozole (LE) to in vitro fertilization (IVF) cycles for mild ovarian stimulation is a general approach. Although lots of researches have demonstrated partial benefits of the strategy, all-around effects of oral medications remained deficient. This paper aims to assess whether an addition of oral medication will result in considerable outcomes on T-Gn (total dose of gonadotropin), Gn days, total retrieved ova, high quality embryos, blastocyst number, ovarian hyperstimulation syndrome (OHSS) rate, clinical pregnancy rate and cumulative pregnancy rate, even if it was not conventional mild/minimal stimulations. RESULTS Participants were categorized to three diverse populations as high responders, normal responders and poor responders according to basal antral follicle count. T-Gn in patients treated with CC/LE distinctly decreased from 2496.96 IU/d to 1827.68 IU/d, from 2860.28 IU/d to 2119.99 IU/d, and from 3182.15 IU/d to 1802.84 IU/d, respectively. For high ovary responders and normal responders, the OHSS incidence rate also declined from 29.2 to 4.3% (P < 0.001) and from 1.1 to 0.0% (P = 0.090). Other, there was no statistical difference with respect to the T-retrieved ova (total retrieved ova), high quality embryos, cultured blastocyst and blastocyst number in high responders. For normal responders and poor ovary responders, T-Gn, Gn days, T-retrieved ova, high quality embryos, cultured blastocyst and blastocysts number in oral medications group all apparently decreased. Clinical pregnancy rate per fresh cycle of poor responders with prior oral medications was significantly decreased (25.7% vs. 50.8%, P = 0.005), and no significant differences in high responders and normal responders were expressed (52.5% vs. 44.2%, P = 0.310; 51.9% vs. 42.4%, P = 0.163) between two groups of participants. The numbers of cumulative pregnancy rates were lower in the conventional group compared to the add group for high (75.90% versus 81.03%, P = 0.279), normal (62.69% versus 71.36%, P = 0.016) and poor (39.74% versus 68.21%, P < 0.001) responders. CONCLUSIONS The addition of CC/LE to the ovulation induction during IVF has certain efficacy in terms of low cost, low OHSS incidence. CC/LE deserves more recommendations as a responsible strategy in high responders due to advantageous pregnancy outcomes. For normal responders, the strategy needs to be considered with more comprehensive factors.
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Affiliation(s)
- Ying Liang
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province, China.
| | - Qing Guo
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province, China
| | - Xiao-Hua Wu
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province, China
| | - Li-Nan Zhang
- Department of Pathology and Pathophysiology, Hebei Medicine University, Shijiazhuang, Hebei, China
| | - Jun Ge
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province, China
| | - Mei-Ling Xu
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province, China
| | - Zheng-Li Feng
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province, China
| | - Xiao-Qian Wu
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province, China
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11
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Abstract
Letrozole, an aromatase inhibitor that blocks estrogen synthesis by inhibiting the final step of the estrogen biosynthetic pathway, has been used in the applications of a wide range of infertility settings. It has been more than 20 years since the initial clinical trial of letrozole for ovulation induction. In light of the accumulating clinical and basic evidence, the efficacy and safety of letrozole have been identified. This mini review focuses on our current knowledge of the applications and mechanisms of letrozole for female infertility and various questions are put forward about how letrozole could be more effectively used.
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12
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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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13
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Haas J, Casper RF. In vitro fertilization treatments with the use of clomiphene citrate or letrozole. Fertil Steril 2017; 108:568-571. [PMID: 28965550 DOI: 10.1016/j.fertnstert.2017.08.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 08/10/2017] [Indexed: 01/30/2023]
Abstract
There has been increasing interest in combining the oral agents clomiphene citrate (CC) and letrozole with gonadotropins in IVF: for poor responders to reduce the amount of gonadotropins used, and in normal responders to reduce the incidence of ovarian hyperstimulation (OHSS). In normal responders, mild stimulation with the use of CC and gonadotropins was found to decrease the number of oocytes retrieved and result in good pregnancy rates, but in most studies the cumulative pregnancy rate was lower compared with conventional ovarian stimulation when frozen embryo transfers were considered. Coadministration of letrozole and gonadotropins has mainly been used in patients with breast cancer to prevent the massive elevation of serum E2 concentrations with the use of standard controlled ovarian hyperstimulation. CC and letrozole have both been used with gonadotropins in poor responders and have been shown to reduce the amount of gonadotropin used without reducing the pregnancy rate. Letrozole use with gonadotropins in IVF cycles may increase endometrial receptivity by increasing integrin expression in the endometrium and by lowering estrogen concentrations to more physiologic levels.
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Affiliation(s)
- Jigal Haas
- Division of Reproductive Sciences, University of Toronto; Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital; and TRIO Fertility, Toronto, Ontario, Canada
| | - Robert F Casper
- Division of Reproductive Sciences, University of Toronto; Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital; and TRIO Fertility, Toronto, Ontario, Canada.
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14
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Abstract
The field of assisted reproductive technology is rapidly progressing with many new advances in the last decade. The present review discusses methods to improve oocyte quality in older women and new stimulation protocols that may improve the number of mature oocytes retrieved during an in vitro fertilization cycle. We will discuss the present use of pre-implantation genetic screening (PGS) and finally focus on some new methods to determine endometrial receptivity. The focus of this review is to point out areas of technology that may be controversial or are new enough to require proper controlled studies for validation.
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Affiliation(s)
- Robert Casper
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, University of Toronto and TRIO Fertility, Toronto, Ontario, Canada.,Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada.,Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Jigal Haas
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, University of Toronto and TRIO Fertility, Toronto, Ontario, Canada
| | - Tzu-Bou Hsieh
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, University of Toronto and TRIO Fertility, Toronto, Ontario, Canada
| | - Rawad Bassil
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, University of Toronto and TRIO Fertility, Toronto, Ontario, Canada
| | - Chaula Mehta
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, University of Toronto and TRIO Fertility, Toronto, Ontario, Canada
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15
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Siristatidis C, Dafopoulos K, Vrantza T, Salamalekis G, Basios G, Vogiatzi P, Pergialiotis V, Papantoniou N. Mild versus conventional antagonist ovarian stimulation protocols in expected normal responders undergoing IVF/ICSI: a case-control study. Gynecol Endocrinol 2017; 33:553-556. [PMID: 28277113 DOI: 10.1080/09513590.2017.1296128] [Citation(s) in RCA: 4] [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: 12/28/2022] Open
Abstract
Mild controlled ovarian hyperstimulation (COH) protocols combining clomiphene citrate (CC) or letrozole with gonadotropins were introduced as an effective alternative of conventional COH in normal responders undergoing IVF/ICSI. In this case-control study, we compared 41 participants treated with a mild stimulation protocol receiving gonadotropins combined with either CC (n = 24) or letrozole (n = 17) with 71 subfertile participants with matching baseline characteristics, conforming with the same inclusion criteria and treated with a conventional antagonist protocol. Live birth was determined in reduced rates in the study group compared to the control group, reaching marginal statistical significance [4/41 versus 19/71, p = 0.050], as also in the respective number of clinical pregnancies [6/41 versus 22/71, p = 0.054], although the incidence of miscarriage was similar for both groups [2/41 versus 5/71, p = 0.714]. Most of the secondary parameters examined, favored the conventional antagonist protocol. There was no difference in any of the outcomes reported between the three different stimulation groups in post-hoc analysis. Mild stimulation regimens with the aid of either CC or letrozole employing GnRH antagonists do not seem to constitute an equally effective method as compared to the conventional antagonist protocol to be offered in good prognosis subfertile women seeking an induced cycle toward IVF/ICSI.
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Affiliation(s)
- Charalampos Siristatidis
- a Assisted Reproduction Unit, Third Department of Obstetrics and Gynecology, "Attikon Hospital", Medical School, National and Kapodistrian University of Athens , Athens , Greece and
| | - Konstantinos Dafopoulos
- b Assisted Reproduction Unit, Department of Obstetrics and Gynecology, School of Health Sciences, Faculty of Medicine, University of Thessaly , Larissa , Greece
| | - Tereza Vrantza
- a Assisted Reproduction Unit, Third Department of Obstetrics and Gynecology, "Attikon Hospital", Medical School, National and Kapodistrian University of Athens , Athens , Greece and
| | - George Salamalekis
- a Assisted Reproduction Unit, Third Department of Obstetrics and Gynecology, "Attikon Hospital", Medical School, National and Kapodistrian University of Athens , Athens , Greece and
| | - George Basios
- a Assisted Reproduction Unit, Third Department of Obstetrics and Gynecology, "Attikon Hospital", Medical School, National and Kapodistrian University of Athens , Athens , Greece and
| | - Paraskevi Vogiatzi
- a Assisted Reproduction Unit, Third Department of Obstetrics and Gynecology, "Attikon Hospital", Medical School, National and Kapodistrian University of Athens , Athens , Greece and
| | - Vasileios Pergialiotis
- a Assisted Reproduction Unit, Third Department of Obstetrics and Gynecology, "Attikon Hospital", Medical School, National and Kapodistrian University of Athens , Athens , Greece and
| | - Nikolaos Papantoniou
- a Assisted Reproduction Unit, Third Department of Obstetrics and Gynecology, "Attikon Hospital", Medical School, National and Kapodistrian University of Athens , Athens , Greece and
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