1
|
Ling L, Xia D, Jin Y, Hong R, Wang J, Liang Y. Effect of follicle size on pregnancy outcomes in patients undergoing first letrozole-intrauterine insemination. Eur J Med Res 2024; 29:184. [PMID: 38500174 PMCID: PMC10949705 DOI: 10.1186/s40001-024-01794-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 03/13/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Letrozole has been proven to be an effective method for inducing ovulation. However, little attention has been paid to whether the lead follicle size will affect the success rate of intrauterine insemination (IUI) with ovulation induction with alone letrozole. Therefore, we hope to investigate the effect of dominant follicle size on pregnancy outcomes on human chorionic gonadotropin (hCG) day of the first letrozole-IUI. METHODS A retrospective cohort study design was employed. We included patients with anovulation or unexplained infertility undergoing first IUI treatment with letrozole for ovarian stimulation. According to the dominant follicle size measured on the day of hCG trigger, patients were divided into six groups (≤ 18 mm, 18.1-19.0 mm, 19.1-20.0 mm, 20.1-21.0 mm, 21.1-22.0 mm, > 22 mm). Logistic models were used for estimating the odds ratios (ORs) with their 95% confidence interval (CIs) for achieving a clinical pregnancy or a live birth. A restricted cubic spline was drawn to explore the nonlinear relationship between follicle size and IUI outcomes. RESULTS A total of 763 patients underwent first letrozole-IUI cycles in our study. Fisher exact test showed significant differences among the six follicle-size groups in the rates of pregnancy, clinical pregnancy and live birth (P < 0.05 in each group). After adjusting the potential confounding factors, compared with the follicles ≤ 18 mm in diameter group, 19.1-20.0 mm, 20.1-21.0 mm groups were 2.3 or 2.56 times more likely to get live birth [adjusted OR = 2.34, 95%CI (1.25-4.39); adjusted OR = 2.56, 95% CI (1.30-5.06)]. A restricted cubic spline showed an inverted U-shaped relationship between the size of dominant follicles and pregnancy rate, clinical pregnancy rate, and live birth rate, and the optimal follicle size range on the day of hCG trigger was 19.1-21.0 mm. When the E2 level on the day of hCG trigger was low than 200 pg/mL, the clinical pregnancy rates of 19.1-20.0 mm, 20.1-21.0 mm groups were still the highest. CONCLUSIONS The optimal dominant follicle size was between 19.1 and 21.0 mm in hCG-triggered letrozole-IUI cycles. Either too large or too small follicles may lead to a decrease in pregnancy rate. Using follicle size as a predicator of pregnancy outcomes is more meaningful when estrogen on the day of hCG trigger is less than 200 pg/ml.
Collapse
Affiliation(s)
- Li Ling
- Reproductive Medicine Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, People's Republic of China
| | - Di Xia
- Reproductive Medicine Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, People's Republic of China
| | - Yihan Jin
- Reproductive Medicine Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, People's Republic of China
| | - Renyun Hong
- Reproductive Medicine Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, People's Republic of China
| | - Jing Wang
- Reproductive Medicine Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, People's Republic of China
| | - Yuanjiao Liang
- Reproductive Medicine Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, People's Republic of China.
| |
Collapse
|
2
|
Feferkorn I, Suarthana E, Nassiri Kigloo H, Kadour Peero E, Hizkiyahu R, Buckett W. Estimation of follicular growth-widely used, seldom studied. HUM FERTIL 2023; 26:1173-1178. [PMID: 36398709 DOI: 10.1080/14647273.2022.2145916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 07/11/2022] [Indexed: 11/19/2022]
Abstract
We assessed whether estimation of follicular growth, rather than actual measurement of follicular size on the day of hCG trigger, affected pregnancy rates in intrauterine insemination (IUI) cycles. Patient and cycle characteristics were extracted from an existing database. Comparisons were made between the pregnant (defined as a positive beta hCG) and non-pregnant groups for the following variables: patient's age, number of previous IUI cycles, type of ovarian stimulation, endometrial thickness, number of follicles measuring 14 mm and above, pre and post wash sperm parameters, cycle day when IUI was done and number of days between last ultrasound scan and ovulation trigger. A total of 7302 cycles were included in the final analysis. In 4055 cycles (55.5%) the hCG trigger was on the day of the last ultrasound, in 2285 cycles (31.3%) the hCG trigger was 1 day after the last ultrasound, in 850 (11.6%) it was 2 days after the last ultrasound and in 112 (1.5%) it was 3 or more days after the last ultrasound. Sperm parameters, younger maternal age, and the number of follicles above 14 mm were all associated with pregnancy. No association was found between positive pregnancy test rates and the time from last ultrasound to hCG trigger. Planning IUI based on the estimation of follicular growth 1-4 days before trigger, does not affect pregnancy rates.
Collapse
Affiliation(s)
- Ido Feferkorn
- Division of Reproductive Endocrinology and Infertility, McGill University Health Care Center, Montréal, Canada
| | - Eva Suarthana
- Division of Reproductive Epidemiology, McGill University Health Care Center, Montreal, Canada
| | - Hormoz Nassiri Kigloo
- Division of Reproductive Epidemiology, McGill University Health Care Center, Montreal, Canada
| | - Einav Kadour Peero
- Division of Reproductive Endocrinology and Infertility, McGill University Health Care Center, Montréal, Canada
| | - Ranit Hizkiyahu
- Division of Reproductive Endocrinology and Infertility, McGill University Health Care Center, Montréal, Canada
| | - William Buckett
- Division of Reproductive Endocrinology and Infertility, McGill University Health Care Center, Montréal, Canada
| |
Collapse
|
3
|
Chen L, Jiang S, Xi Q, Li W, Lyu Q, Kuang Y. Optimal lead follicle size in letrozole human menopausal gonadotrophin intrauterine insemination cycles with and without spontaneous LH surge. Reprod Biomed Online 2023; 46:566-576. [PMID: 36456392 DOI: 10.1016/j.rbmo.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/28/2022] [Accepted: 11/03/2022] [Indexed: 11/09/2022]
Abstract
RESEARCH QUESTION What is the optimal lead follicle size in letrozole, human menopausal gonadotrophin and intrauterine insemination (IUI) cycles with and without spontaneous LH surges? DESIGN This retrospective cohort study included 3797 letrozole HMG IUI cycles between January 2010 and May 2021. All cycles were divided into two groups: the HCG trigger group (trigger day LH ≤15 mIU/ml) and the spontaneous LH surge group (trigger day LH >15 mIU/ml). These two groups were subdivided into smaller groups based on the diameter of the follicles. The primary outcome measure was clinical pregnancy rate. Logistic regression analysis was conducted to explore other risk factors. RESULTS In the HCG trigger group, the clinical pregnancy rate varied significantly, with rates of 20.8%, 14.9% and 11.8% for the 16.1-18.0, 18.1-20.0 and 20.1-22.0 mm groups, respectively (P = 0.005). In the spontaneous LH surge group, the pregnancy rate of follicles within 14.1-16.0 mm was significantly higher than that of follicles within 20.1-22.0 mm (adjusted OR 0.533, 95% CI 0.308 to 0.923, P = 0.025). Also, patients with two lead follicles were 2.569 times more likely to achieve a clinical pregnancy than those with only one lead follicle (adjusted OR 2.569, 95% CI 1.258 to 5.246, P = 0.010). The duration of infertility was also found to be a common influencing factor in both groups. CONCLUSIONS The optimal lead follicle size was between 16.1 and 18.0 mm in HCG-triggered letrozole HMG IUI cycles. If the lead follicle size is relatively small (14.1-18.0 mm) when a spontaneous LH surge occurs, there is no need to cancel the IUI cycle.
Collapse
Affiliation(s)
- Li Chen
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine Shanghai, People's Republic of China.
| | - Shutian Jiang
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine Shanghai, People's Republic of China.
| | - Qianwen Xi
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine Shanghai, People's Republic of China.
| | - Wenzhi Li
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine Shanghai, People's Republic of China
| | - Qifeng Lyu
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine Shanghai, People's Republic of China
| | - Yanping Kuang
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine Shanghai, People's Republic of China
| |
Collapse
|
4
|
Yang J, Gao J, Wang Y, Liu H, Lian X. Impact of follicular size categories on oocyte quality at trigger day in young and advanced-age patients undergoing GnRH-ant therapy. Front Endocrinol (Lausanne) 2023; 14:1167395. [PMID: 37124736 PMCID: PMC10140496 DOI: 10.3389/fendo.2023.1167395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 03/30/2023] [Indexed: 05/02/2023] Open
Abstract
Aim To study the effect of follicle sizes of different proportions on oocyte and embryo quality in young and advanced-age patients, and provide evidence for personalized protocol adjustment. Methods This was a retrospective real-world data study including a total of 11,462 patients who had started their first in vitro fertilization cycle with a gonadotropin-releasing hormone antagonist (GnRH-ant) protocol during 2018-2021. We classified patients into groups according to the size of the dominant proportion of follicles on the human chorionic gonadotropin (hCG) trigger day: Large, Medium, Small, and Equal (containing equivalent proportions of all three size categories). The Cochran-Mantel-Haenszel test by different Anti-Mullerian Hormone (AMH) and antral follicle count (AFC) was used to compare factors such as the metaphase II (MII) oocyte rate, normal fertilization rate, and two pronuclei (2PN) cleavage rate between groups. General linear model (GLM) analysis was performed for inter-group comparison of the oocyte and embryo quality. Results In patients aged < 35 years and with AMH ≥ 1.2μg/L, the MII oocyte percentages in the Large and Medium groups were significantly higher than in the Small group (P < 0.001). The germinal vesicle (GV) oocyte and unavailable oocyte percentages in the Large and Medium groups were lower than in the Small group (P < 0.001). Among patients aged ≥ 35 years with AFC < 5 and AMH ≥ 1.2μg/L, the GV oocyte percentage in the Large group was significantly lower than in the Medium group (2.54% vs. 4.46%, P < 0.001). In patients < 35 years, the GLM demonstrated that the Large and Medium groups had positively impacted on the development of MII oocyte and live birth rate(LBR) of first embryo transfer(ET)(β>0, all P value < 0.05);and had less likely to develop into unavailable oocyte, degenerated oocyte, GV oocyte and MI oocyte rates relative to the Small group(β<0, all P value < 0.05). And among patients ≥ 35 years, the Medium group had positively impacted on the development of MII oocyte and 2PN rates relative to the Small group(β>0, all P value < 0.05); and had less likely to develop into MI oocytes relative to the Small group(β<0, all P value < 0.05). The GLM indicated that AMH, along with Gn total dose, start dose, and Gn days, had significant impact on oocyte and embryo quality. For young patients, age was not a significant influencing factor, but for advanced-age patients, age influenced the outcomes. Conclusion Our analysis suggests that for young patients (< 35 years), triggering when there is a high proportion of large or medium follicles results in better quality oocytes, while for older patients (≥ 35 years), it is better to trigger when the proportion of medium follicles is no less than that of small follicles. Further research is required to confirm these findings.
Collapse
Affiliation(s)
- Jingwei Yang
- Chongqing Key Laboratory of Human Embryo Engineering, Center for Reproductive Medicine, Women and Children’s Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Clinical Research Center for Reproductive Medicine, Chongqing Health Center for Women and Children, Chongqing, China
- School of Public Health, Chongqing Medical University, Chongqing, China
| | - Jing Gao
- Department of Academic Affairs, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yuting Wang
- Department of Medical Records and Statistics, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hongya Liu
- School of Public Health, Chongqing Medical University, Chongqing, China
| | - Xuemei Lian
- School of Public Health, Chongqing Medical University, Chongqing, China
- *Correspondence: Xuemei Lian,
| |
Collapse
|
5
|
Shah N, Romanski PA, Bortoletto P, Rosenwaks Z, Kligman I. Determining the optimal follicle size at trigger in patients undergoing ovarian stimulation with a clomiphene citrate plus gonadotropin and GnRH antagonist protocol for in vitro fertilization. Minerva Obstet Gynecol 2021; 74:75-82. [PMID: 34180612 DOI: 10.23736/s2724-606x.21.04837-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Determine the optimal follicle size at trigger in clomiphene citrate-based IVF protocols. STUDY DESIGN This is a retrospective cohort study performed in at a single academic institution that included first IVF cycles with clomiphene citrate-based protocols at our center between 01/01/2013-03/31/2019. Patients were dichotomized by whether they had ≥2 follicles >20 mm on trigger day. Group A consisted of patients with <2 follicles >20 mm on trigger day and Group B consisted of patients with ≥2 follicles >20 mm on trigger day. The primary outcome was the number of mature oocytes retrieved. Secondary outcomes included pregnancy and live birth rates. RESULTS A total of 635 patients were included: (Group A = 399 patients and Group B = 236 patients). The median (IQR) diameter of the largest follicle was 20.0 mm (19.0-21.0) in Group A and 22.7 mm (21.8-24.0) in Group B (p < 0.001). Among the entire cohort, mean number of oocytes retrieved was significantly higher in Group B (9.9 ± 6.5; RR 1.08 (95% CI 1.03-1.14)) compared to Group A (9.2 ± 6.3). In a subgroup analysis of patients in the upper quartile for age (≥41.7 years), Group B had significantly more oocytes retrieved (8.1 ± 5.9 vs. 6.7 ± 4.5; RR 1.23 (95% CI 1.10-1.38)), more mature oocytes retrieved (6.0 ± 4.0 vs. 5.2 ± 3.4; RR 1.16 (95% CI 1.02-1.33)), and more zygotes (4.7 ± 3.5 vs. 3.6 ± 2.8; RR 1.32 (95% CI 1.13-1.55)). In the secondary analysis, pregnancy and live birth rates after fresh transfer were similar between groups. CONCLUSIONS In clomiphene citrate-based IVF protocols, administering the ovulatory trigger at larger follicle sizes yielded more total oocytes retrieved without a significant difference in mature oocyte number. In older patients, larger follicle sizes at trigger yielded more mature oocytes and zygotes per retrieval. Based on these results, in older patients it may be advantageous to administer the ovulatory trigger in clomiphene-based IVF cycles when two or more follicles measures >20 mm. However, this benefit was not observed when assessed among all ages combined.
Collapse
Affiliation(s)
- Nirali Shah
- Department of Obstetrics & Gynecology, Weill Cornell Medicine, New York, NY, USA
| | - Phillip A Romanski
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, NY, USA -
| | - Pietro Bortoletto
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, NY, USA
| | - Zev Rosenwaks
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, NY, USA
| | - Isaac Kligman
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, NY, USA
| |
Collapse
|
6
|
Optimal lead follicle size for human chorionic gonadotropin trigger in clomiphene citrate and intrauterine insemination cycles: an analysis of 1,676 treatment cycles. Fertil Steril 2020; 115:984-990. [PMID: 33272641 DOI: 10.1016/j.fertnstert.2020.10.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 05/21/2020] [Accepted: 10/02/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To identify the optimal lead follicle size for hCG trigger in clomiphene citrate (CC)-intrauterine insemination (IUI) cycles. DESIGN Retrospective cohort study. SETTING University-affiliated center. PATIENT(S) Patients <40 years of age with ovulatory dysfunction or unexplained infertility undergoing their first CC-IUI cycle. INTERVENTION(S) Ovulation induction, hCG trigger, and IUI. MAIN OUTCOME MEASURE(S) Clinical pregnancy rate (CPR) was the primary outcome and was plotted against lead follicle size in increments of 1 mm. Odds ratios with 95% confidence intervals for associations between lead follicle size and CPR were calculated from a multivariable logistic regression model. A receiver operating characteristic (ROC) curve was generated for CPR as a function of lead follicle size. RESULT(S) 1,676 cycles were included. The overall CPR was 13.8% (232/1,676). There was no difference in baseline demographics or ovulation induction parameters of patients who did or did not conceive. The odds of clinical pregnancy were 2.3 and 2.2 times higher with lead follicle sizes of 21.1-22.0 mm and >22.0 mm, respectively, compared with the referent category of 19.1-20.0 mm. Lead follicle size was an independent predictor of CPR, even after accounting for confounders. A lead follicle size of 22.1 mm corresponded to a sensitivity and specificity of 80.1% and 90.4% for clinical pregnancy, respectively, with an area under the ROC curve of 0.89. CONCLUSION(S) hCG administration at a lead follicle size of 21.1-22.0 mm is associated with higher odds of clinical pregnancy in patients undergoing their first CC-IUI cycles for ovulatory dysfunction or unexplained infertility.
Collapse
|
7
|
Kahraman S, Çetinkaya CP, Çetinkaya M, Tüfekçi MA, Ekmekçi CG, Montag M. Is there a correlation between follicle size and gene expression in cumulus cells and is gene expression an indicator of embryo development? Reprod Biol Endocrinol 2018; 16:69. [PMID: 30031399 PMCID: PMC6054838 DOI: 10.1186/s12958-018-0388-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 07/10/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND In an article published in 2017, we discussed the results of the first part of our study into the morphokinetic development of embryos in relation to follicle diameter and homogeneity of follicular development. Our findings showed that embryos coming from small follicles in heterogeneous cycles had significantly higher rates of arrest or failure to reach blastocyst than embryos coming from large follicles in homogenous cycles. The aim of this further study was to investigate the relationship between follicular size and gene expression of cumulus cells (CCs) and evaluate whether gene expression could be an indicator of embryo development. METHODS This study was based on 2495 COCs from 184 patients. CC expressions of five genes (TNFAIP6, PTGS2, HAS2, PTX3 and GDF9) were studied by generalized linear mixed models (GLMMs) regarding follicular size. CC expressions were then separately analysed regarding patient-specific variables (age, BMI, AMH and follicular size) in relation to embryos reaching blastocyst (eRB) or top or good quality blastocysts (TQ + GQ) using GLMMs with logit link. RESULTS Follicular size significantly correlated with the potential of an oocyte to develop into a blastocyst: oocytes developing from large follicles were more than twice as likely to develop into an eRB than oocytes from small follicles (p < 0.001). Gene expression of HAS2 and GDF9 correlated with blastocyst quality when separately evaluated with follicular size and the patient specific variables of age, BMI and AMH. However, no such correlation was found in other gene expressions studied. CONCLUSIONS Our findings suggest that differences in the expression of genes studied could be related to follicular size rather than to embryo quality. Although gene expression of HAS2 and GDF9 correlated with blastocyst quality, the only variable correlating with eRB and TQ and GQ blastocysts for each of these five models was follicular size. TRIAL REGISTRATION This prospective cohort study was registered at clinicaltrials.gov (NCT02230449).
Collapse
Affiliation(s)
- Semra Kahraman
- Istanbul Memorial Hospital, Assisted Reproductive Technologies and Reproductive Genetics Centre, Piyale Pasa Bulvari 34385 Okmeydani Sisli, Istanbul, Turkey.
| | - Caroline Pirkevi Çetinkaya
- Istanbul Memorial Hospital, Assisted Reproductive Technologies and Reproductive Genetics Centre, Piyale Pasa Bulvari 34385 Okmeydani Sisli, Istanbul, Turkey
| | - Murat Çetinkaya
- Istanbul Memorial Hospital, Assisted Reproductive Technologies and Reproductive Genetics Centre, Piyale Pasa Bulvari 34385 Okmeydani Sisli, Istanbul, Turkey
| | - Mehmet Ali Tüfekçi
- Istanbul Memorial Hospital, Assisted Reproductive Technologies and Reproductive Genetics Centre, Piyale Pasa Bulvari 34385 Okmeydani Sisli, Istanbul, Turkey
| | - Cumhur Gökhan Ekmekçi
- Istanbul Memorial Hospital, Assisted Reproductive Technologies and Reproductive Genetics Centre, Piyale Pasa Bulvari 34385 Okmeydani Sisli, Istanbul, Turkey
| | - Markus Montag
- ilabcomm GmbH, Eisenachstr. 34, 53757, Sankt Augustin, Germany
| |
Collapse
|
8
|
Bathwal S, Chakravarty A, Sharma S, Singh S, Saha I, Chakravarty B. Efficacy of GnRH agonist trigger in women having history of follicular-endometrial asynchrony with clomiphene/IUI cycles in unexplained infertility. Arch Gynecol Obstet 2018; 298:427-432. [PMID: 29955952 DOI: 10.1007/s00404-018-4834-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 06/19/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE An alternative option to human chorionic gonadotropin (hCG) is GnRH agonist (GnRH-a) for ovulation trigger in intrauterine insemination (IUI) cycles. This study aims to compare the efficacy of GnRH-a with hCG in women with history of follicular-endometrial asynchrony after clomiphene in IUI cycles. METHODS This prospective observational study recruited 631 women with unexplained infertility and follicular-endometrial asynchrony (follicle ≥ 18 mm, endometrial thickness (ET) < 7 mm) in previous two failed clomiphene/IUI cycles. Overall 27 patients with synchronized follicular-endometrial relationship and 49 women with persistent ET < 7 mm and/or follicle > 26 mm were excluded. Remaining women (n = 555) were divided into two groups: Group A (n = 285) received GnRH-a and Group B (n = 270) received hCG ovulation trigger. Finally, 513 patients, who underwent IUI, were analysed. RESULTS Cancellation due to luteinized unruptured follicle was more in hCG group (P = 0.01). Higher clinical pregnancies (10.33 vs. 4.96%, P = 0.03) and live birth rates (8.86 vs. 4.13%, P = 0.03) were noted with GnRH-a trigger. Miscarriage rate was comparable in both the groups (10.71 and 16.67% in Group A and Group B, respectively). CONCLUSION In unexplained infertility, GnRH agonist is an useful alternative for triggering ovulation in women with follicular-endometrial asynchrony following clomiphene induction.
Collapse
Affiliation(s)
- Shikha Bathwal
- Institute of Reproductive Medicine, HB-36/A/3, Sector-III, Salt Lake City, Kolkata, 700106, India
| | - Astha Chakravarty
- Institute of Reproductive Medicine, HB-36/A/3, Sector-III, Salt Lake City, Kolkata, 700106, India
| | - Sunita Sharma
- Institute of Reproductive Medicine, HB-36/A/3, Sector-III, Salt Lake City, Kolkata, 700106, India.
| | - Soma Singh
- Institute of Reproductive Medicine, HB-36/A/3, Sector-III, Salt Lake City, Kolkata, 700106, India
| | - Indranil Saha
- Institute of Reproductive Medicine, HB-36/A/3, Sector-III, Salt Lake City, Kolkata, 700106, India
| | - Baidyanath Chakravarty
- Institute of Reproductive Medicine, HB-36/A/3, Sector-III, Salt Lake City, Kolkata, 700106, India
| |
Collapse
|
9
|
Maher MA, Abdelaziz A, Shehata YA. Effect of follicular diameter at the time of ovulation triggering on pregnancy outcomes during intrauterine insemination. Int J Gynaecol Obstet 2017; 139:174-179. [PMID: 28771718 DOI: 10.1002/ijgo.12291] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 06/11/2017] [Accepted: 08/01/2017] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To compare pregnancy outcomes when triggering ovulation at different follicle sizes during intrauterine insemination (IUI) cycles. METHODS A prospective observational study was undertaken at two collaborative fertility centers in Saudi Arabia between January 2014 and May 2016. Women of any age were enrolled if they met inclusion criteria: primary, secondary, or unexplained infertility (≥1 year); day-2 follicle-stimulating hormone less than 12 IU/mL; normal prolactin, thyroid function, and uterine cavity; at least one patent tube; and a male partner with normal semen count and motility. IUI cycles were subdivided by size of dominant follicle (17 to <18 mm, 18 to <19 mm, 19 to <20 mm, and ≥20 mm), and pregnancy outcomes compared. RESULTS Data from 516 IUI cycles were analyzed. Frequencies of clinical pregnancy, ongoing pregnancy, and live birth for a follicle size of 19-20 mm were 30.2% (39/129), 24.0% (31/129), and 24.0% (31/129), respectively; these rates were significantly higher than those in other groups (all P<0.05). Only endometrial thickness was found to also contribute to outcome: probability of pregnancy increased as thickness rose (odds ratio 1.148, 95% confidence interval 1.065-1.237; P<0.001). CONCLUSION The optimal follicular diameter associated with increased pregnancy rates in gonadotropin-stimulated IUI cycles was between 19 and 20 mm.
Collapse
Affiliation(s)
- Mohammad A Maher
- Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Shebin-Elkom, Egypt.,Al-Hayat National Hospital, Khamis-Mushait, Saudi Arabia
| | - Ahmed Abdelaziz
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain-shams University, Cairo, Egypt.,Armed Forces Hospital North-West Region, Tabouk, Saudi Arabia
| | - Yasser A Shehata
- Department of Public Health and Community Medicine, Menoufia University, Shebin-Elkom, Egypt
| |
Collapse
|
10
|
The effect of follicle size and homogeneity of follicular development on the morphokinetics of human embryos. J Assist Reprod Genet 2017; 34:895-903. [PMID: 28470453 PMCID: PMC5476546 DOI: 10.1007/s10815-017-0935-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 04/25/2017] [Indexed: 01/01/2023] Open
Abstract
Purpose Our aim was to investigate follicular size (large, ≥17 mm and small, <17 mm) at the time of OPU and homogeneity of follicular development (homogenous development: follicles being present in a homogenous spread of all sizes; heterogeneous: a predominance of small and large follicles) by analysing the morphokinetics of embryo development. Methods In this prospective cohort study, 2526 COCs belonging to 187 patients were cultured to day 5. Embryos were evaluated morphokinetically. Four subgroups were defined: large follicles from heterogeneous cycles (LHet) and homogenous cycles (LHom) and small follicles from heterogeneous cycles (SHet) and homogenous cycles (SHom). Results Rates of fertilization, blastocyst formation and top and good quality blastocysts were found to be significantly higher in embryos from the LHom group (p < 0.001; p < 0.001; p < 0.001). Small follicles from both homogenous and heterogeneous cycles had significantly lower blastocyst formation and top and good quality blastocyst rates (p < 0.001; p < 0.001). Embryos from SHet had significantly more direct cleavages (p = 0.011). Time to reach blastocyst was shorter in SHom than LHet and LHom (p = 0.002; p = 0.027, respectively). However, once the blastocyst stage was achieved, implantation rates were not significantly different between subgroups, the highest rate being observed in the LHom group. Multivariable analysis revealed that homogeneity of follicular development and follicular size had a significant effect on blastocyst development and quality (p = 0.049; p < 0.001, respectively). Conclusion Follicular dynamics, illustrated by follicular size and homogeneity of follicular development, influence early human embryo development. Patterns of follicular growth have an impact on embryo quality and viability which is reflected in morphokinetic variables. Electronic supplementary material The online version of this article (doi:10.1007/s10815-017-0935-1) contains supplementary material, which is available to authorized users.
Collapse
|
11
|
Sun XJ, Jiang L, Ji LC, Nie R, Chen H, Jin L, Zhu GJ, Qian K. A retrospective analysis of ovarian stimulation with letrozole in women undergoing artificial insemination by donor. Reprod Biomed Online 2017; 34:354-360. [PMID: 28187961 DOI: 10.1016/j.rbmo.2017.01.008] [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: 06/27/2016] [Revised: 01/07/2017] [Accepted: 01/11/2017] [Indexed: 10/20/2022]
Abstract
The aim of this retrospective study was to determine the clinical pregnancy rate in women undergoing letrozole ovarian stimulation and artificial insemination by donor (AID). Between 2012 and 2015, 130 natural cycles, 939 letrozole cycles and 130 letrozole plus gonadotrophin cycles were conducted. Letrozole cycles were divided into three groups according to LH concentration on the day of HCG administration (LH <10 mIU/ml and follicle size ≥18 cm; LH ≤10 to <20 mIU/ml; and LH ≥20 mIU/ml). Pregnancy rates were 17.3%, 22.4% and 26.8%, respectively (P = 0.012). In women given 10 mIU/ml LH or more, logistic regression identified oestradiol (OR 1.002, 95% CI, 1.000 to 1.004, P = 0.029) and leading follicle size (OR 0.861, 95% CI, 0.772 to 0.960, P = 0.007) as significant predictive factors of pregnancy rate; the higher the oestradiol and the smaller the follicles, the better the pregnancy rate. The pregnancy rate was significantly higher in the letrozole plus gonadotrophin group than the letrozole group (P = 0.04). Better pregnancy rates can be achieved if LH surge occurs before HCG administration, especially with higher oestradiol and lower follicle size; treatment with letrozole plus gonadotrophin was significantly more effective than letrozole alone in AID.
Collapse
Affiliation(s)
- X J Sun
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, China
| | - L Jiang
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, China
| | - L C Ji
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, China
| | - R Nie
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, China
| | - H Chen
- Department of Rehabilitation Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - L Jin
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, China.
| | - G J Zhu
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, China.
| | - K Qian
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, China.
| |
Collapse
|
12
|
Hershko-Klement A, Tepper R. Ultrasound in assisted reproduction: a call to fill the endometrial gap. Fertil Steril 2016; 105:1394-1402.e4. [DOI: 10.1016/j.fertnstert.2016.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 04/09/2016] [Accepted: 04/11/2016] [Indexed: 10/21/2022]
|
13
|
Nivet AL, Léveillé MC, Leader A, Sirard MA. Transcriptional characteristics of different sized follicles in relation to embryo transferability: potential role of hepatocyte growth factor signalling. Mol Hum Reprod 2016; 22:475-84. [PMID: 27126491 DOI: 10.1093/molehr/gaw029] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 04/25/2016] [Indexed: 01/29/2023] Open
Abstract
STUDY HYPOTHESIS We hypothesized that a better discrimination between follicles containing oocytes with high developmental competence and those containing oocytes with low competence, based on a combination of a follicle's size and transcriptomic signature, will provide a reliable method to predict embryonic outcome of IVF. STUDY FINDING This study provides new insights on the impact of follicular size on oocyte quality as measured by embryonic development and demonstrates that medium follicles yield a better percentage of transferable embryos. WHAT IS KNOWN ALREADY Although it is generally accepted that large ovarian follicles contain better eggs, other studies report that a better follicular size subdivision and a better characterization are needed. STUDY DESIGN, SAMPLES/MATERIALS, METHODS Individual follicles (n = 136), from a total of 33 women undergoing IVF, were aspirated and categorized on the basis of their follicular liquid volume (small, medium or large) and the embryonic outcome of the enclosed oocyte: poor or good development. Comprehensive gene expression analysis between cells from the different sized follicles was performed using microarrays and quantitative RT-PCR to find molecular markers associated with follicular maturity and oocyte developmental competence. MAIN RESULTS AND THE ROLE OF CHANCE The analysis of embryonic outcome in relation to follicular size indicates that the medium-sized follicles category yielded more transferable embryos (35%) compared with the largest follicles (30%) (NS). Gene expression analysis revealed expression markers with significant (P < 0.05) discrimination between the poor development groups for all three follicle sizes, and good development medium-size follicles, including up-regulation of thrombomodulin, transforming growth factor, beta receptor II and chondrolecti, and those associated with hyaluronan synthesis, coagulation and hepatocyte growth factor signalling. LIMITATIONS, REASONS FOR CAUTION These analyses were performed in a single cohort of patients coming from a single clinic and the biomarkers generated will require validation in different geographical and biological contexts to ensure their global applicability. WIDER IMPLICATIONS OF THE FINDINGS Medium-size follicles seem to be the optimal size for a positive embryonic outcome and are associated with competence markers that may help in understanding the ideal differentiation status during late folliculogenesis. LARGE SCALE DATA The data discussed in this publication have been deposited in The National Center for Biotechnology Information Gene Expression Omnibus database and are accessible through GEO Series accession number GSE52851. STUDY FUNDING AND COMPETING INTERESTS This study was supported by Canadian Institutes of Health Research (CIHR) and Natural Sciences and Engineering Research Council of Canada (NSERC) to M.A.S. There are no competing interests to declare.
Collapse
Affiliation(s)
- A L Nivet
- Département des Sciences Animales, Centre de Recherche en Biologie de la Reproduction, Institut sur la Nutrition et les Aliments fonctionnels, Université Laval, 2440 Boulevard Hochelaga, Quebec, QC G1V 0A6, Canada
| | - M C Léveillé
- Ottawa Fertility Clinic, 100-955 Green Valley Crescent, Ottawa, ON K2C 3V4, Canada
| | - A Leader
- Ottawa Fertility Clinic, 100-955 Green Valley Crescent, Ottawa, ON K2C 3V4, Canada
| | - M A Sirard
- Département des Sciences Animales, Centre de Recherche en Biologie de la Reproduction, Institut sur la Nutrition et les Aliments fonctionnels, Université Laval, 2440 Boulevard Hochelaga, Quebec, QC G1V 0A6, Canada
| |
Collapse
|
14
|
Seckin B, Pekcan MK, Bostancı EI, Inal HA, Cicek MN. Comparison of pregnancy rates in PCOS patients undergoing clomiphene citrate and IUI treatment with different leading follicular sizes. Arch Gynecol Obstet 2015; 293:901-6. [PMID: 26563313 DOI: 10.1007/s00404-015-3953-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 10/28/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE The objective of the study was to compare the pregnancy rates in PCOS patients undergoing clomiphene citrate (CC) and intrauterine insemination (IUI) treatment with different leading follicular sizes. METHODS A total of 358 infertile women with PCOS who underwent 563 clomiphene citrate and IUI treatment cycles were included in this prospective study. Treatment cycles were divided into three groups according to leading follicular size on the day of hCG administration: Group I: follicular size 17-18 mm (n = 177), Group II: 19-22 mm (n = 321), and Group III : >22 mm (n = 65). Pregnancy rates were evaluated. Treatment outcomes of the groups were further analyzed related to endometrial thickness measurement on the day of hCG. For this purpose, cycles were placed into three subgroups as follows: endometrial thickness <7, 8-9, and >9 mm. RESULTS There was no statistically significant difference in clinical pregnancy rate per cycle between the groups (8.5, 10, and 9.2 % for Group I, II, and III, respectively, p = 0.86). In further analyses related to endometrial thickness, no significant difference was also found in pregnancy rate among the groups. CONCLUSION This results suggest that pregnancy rate is not related to leading follicle size on the day of hCG administration in PCOS patients treated with CC and IUI. In addition, pregnancy rate in women with different follicular sizes is not influenced by the endometrial thickness.
Collapse
Affiliation(s)
- Berna Seckin
- Department of Reproductive Endocrinology, Zekai Tahir Burak Women's Health Research and Education Hospital, Ankara, Turkey.
| | - Meryem Kuru Pekcan
- Department of Reproductive Endocrinology, Zekai Tahir Burak Women's Health Research and Education Hospital, Ankara, Turkey
| | - Esra Isci Bostancı
- Department of Reproductive Endocrinology, Zekai Tahir Burak Women's Health Research and Education Hospital, Ankara, Turkey
| | - Hasan Ali Inal
- Department of Gynecology and Obstetrics, Konya Research and Training Hospital, Konya, Turkey
| | - Mahmut Nedim Cicek
- Department of Reproductive Endocrinology, Zekai Tahir Burak Women's Health Research and Education Hospital, Ankara, Turkey
| |
Collapse
|
15
|
Portocarrero-Sanchez C, Gomes-Sobrinho DB, Nakagawa HM, Silva AA, Carvalho BRD, Sarkis NT, Peraçoli JC, Cardoso MTDO. The association between follicular size at the time of spontaneous rupture and pregnancy rates in clomiphene citrate treated PCOS patients in coit cycles. Gynecol Endocrinol 2015; 31:392-5. [PMID: 25784169 DOI: 10.3109/09513590.2015.1006186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To investigate the follicular size at spontaneous rupture on pregnancy rate in patients with polycystic ovary syndrome (PCOS) undergoing clomiphene citrate (CC) ovulation. DESIGN Cross-sectional study. PATIENTS AND METHODS One hundred and four women with ovulatory cycles after use of CC followed by ultrasound to determine the follicle size at the time of rupture, which was subsequently correlated with the occurrence of pregnancy or not in coit cycles. RESULTS In the group of follicular rupture at a mean diameter ≤25 mm (n = 54), pregnancy rate was 35.1% and when follicular rupture occurred at a mean diameter >25 mm (n = 50), it was 34% (p > 0.05). When different diameters at follicular rupture were randomly correlated with the pregnancy rate, there was no significant difference. CONCLUSION Our data suggest that the occurrence of pregnancy after ovulation induction with CC in women with PCOS is not associated with follicle size at the time of rupture.
Collapse
|
16
|
Shalom-Paz E, Marzal A, Wiser A, Hyman J, Tulandi T. Does optimal follicular size in IUI cycles vary between clomiphene citrate and gonadotrophins treatments? Gynecol Endocrinol 2014; 30:107-10. [PMID: 24266698 DOI: 10.3109/09513590.2013.860126] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To evaluate pregnancy-related leading follicles during ovulation induction and superovulation with clomiphene citrate (CC) or gonadotropin. DESIGN Retrospective cohort. PATIENTS Five hundred and forty-two women who underwent a total of 615 treatment cycles with CC or gonadotropin. INTERVENTION We evaluated the effects of CC and gonadotropin on the leading follicles, clinical pregnancy rates and miscarriage rate. RESULTS The number of follicles larger than 15 mm in the different protocols was comparable. In those treated with CC, the diameter of the dominant follicles before human chorionic gonadotropins (hCG) trigger in the conception cycles (20.4 ± 1.2 mm) was significantly larger than in the non-conception cycles (18.8 ± 1.9 mm). In women treated with gonadotropin, the diameter of the leading follicle in the conception cycles (18.5 ± 1.7 mm) was comparable to that in the non-conception cycles (18.2 ± 1.7 mm). The pregnancy-related diameter of the leading follicle in CC cycles (20.4 ± 1.2 mm) was significantly larger than that in gonadotropin cycles (18.8 ± 1.9 mm; p = 0.001; 95% CI, -2.2 to -0.9). CONCLUSION Pregnancy-related diameter of the leading follicle in CC cycles is significantly larger than that in gonadotropin cycles and the best time for hCG trigger in the CC cycle is when the leading follicle reaches 20 mm.
Collapse
Affiliation(s)
- Einat Shalom-Paz
- Department of Obstetrics and Gynecology, McGill University, Montreal, QC , Canada
| | | | | | | | | |
Collapse
|
17
|
Palatnik A, Strawn E, Szabo A, Robb P. What is the optimal follicular size before triggering ovulation in intrauterine insemination cycles with clomiphene citrate or letrozole? An analysis of 988 cycles. Fertil Steril 2012; 97:1089-94.e1-3. [DOI: 10.1016/j.fertnstert.2012.02.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Revised: 01/25/2012] [Accepted: 02/14/2012] [Indexed: 11/28/2022]
|
18
|
Homburg R, Hendriks ML, König TE, Anderson RA, Balen AH, Brincat M, Child T, Davies M, D'Hooghe T, Martinez A, Rajkhowa M, Rueda-Saenz R, Hompes P, Lambalk CB. Clomifene citrate or low-dose FSH for the first-line treatment of infertile women with anovulation associated with polycystic ovary syndrome: a prospective randomized multinational study. Hum Reprod 2011; 27:468-73. [PMID: 22128296 DOI: 10.1093/humrep/der401] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Clomifene citrate (CC) is accepted as the first-line method for ovulation induction (OI) in patients with polycystic ovary syndrome (PCOS) associated with infertility owing to anovulation. Low-dose FSH has been reserved for women failing to conceive with CC. In this RCT, we tested the hypothesis that pregnancy rate (PR) and live birth rates (LBR) are higher after OI with low-dose FSH than with CC as first-line treatment. METHODS Infertile women (<40 years old) with PCOS-related anovulation, without prior OI treatment, attending 10 centres in Europe/South America were randomized to OI with either CC (50-150 mg/day for 5 days) or FSH (starting dose 50 IU) for up to three treatment cycles. The primary outcome was clinical PR. RESULTS Patients (n = 302) were randomized to OI with FSH (n = 132 women; 288 cycles) or CC (n = 123; 310 cycles). Per protocol analysis revealed that reproductive outcome was superior after OI with FSH than with CC with respect to PR per first cycle [30 versus 14.6%, respectively, 95% confidence interval (CI) 5.3-25.8, P = 0.003], PR per woman, (58 versus 44% of women, 95% CI 1.5-25.8, P = 0.03), LBR per woman (52 versus 39%, 95% CI 0.4-24.6, P = 0.04), cumulative PR (52.1 versus 41.2%, P = 0.021) and cumulative LBR (47.4 versus 36.9%, P = 0.031), within three cycles of OI. CONCLUSIONS Pregnancies and live births are achieved more effectively and faster after OI with low-dose FSH than with CC. This result has to be balanced by convenience and cost in favour of CC. FSH may be an appropriate first-line treatment for some women with PCOS and anovulatory infertility, particularly older patients.
Collapse
Affiliation(s)
- R Homburg
- Reproductive Medicine, VU University Medical Center, Amsterdam, The Netherlands.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|