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

High estrogen exposure may not be detrimental on endometrial receptivity in women with PCOS

The study aimed to assess the effect of high estrogen exposure and coasting on cycle outcome in women at risk for developing ovarian hyperstimulation syndrome (OHSS). Retrospective case-control study was conducted to figure out the outcomes of GnRH antagonist cycles in which women were at risk to develop OHSS. Women who underwent coasting (n = 100) were compared with a control group of women who did not undergo coasting (n = 287). Effect of endometrial estrogen exposure was determined by calculating area under curve of temporal estrogen measurements (AUCEM) through the cycle. Among 387 women with PCOS, 100 cases were required to undergo coasting to avoid OHSS. All participants reached to embryo transfer stage and clinical pregnancy rate was 44% in group with coasting whereas 39% in group without coasting (p > .05). AUCEM was a significant predictor for the cases who required coasting to avoid OHSS (AUC = 0.754, p < .001). Optimal cut off value was calculated to be 6762 with 71% sensitivity and 67% specificity. ROC analysis showed no predictive value of AUCEM for clinical pregnancy in subgroup of women with coasting (AUC = 0.496, p > .05). Consistently, ROC analysis showed no predictive value of AUCEM for clinical pregnancy in subgroup of women without coasting (AUC = 0.494, p > .05). In conclusion, neither coasting nor the high endometrial estrogen exposure was found to have detrimental effect on endometrial receptivity and cycle outcome in PCOS.

Follicular aspiration versus coasting for ovarian hyper-stimulation syndrome prevention

Objectives:

To compare follicular reduction prior to human chorionic gonadotropin (HCG) trigger and coasting in terms of ovarian hyper-stimulation syndrome (OHSS) reduction, pregnancy, and cancellation rates in in vitro fertilization/ intracytoplasmic sperm injection (IVF/ICSI) cycles.

Methods:

This study was designed as a prospective study. The setting was the IVF unit at King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia. A total of 39 patients undergoing IVF/ICSI cycles, who were at risk of OHSS, 20 were put into a coasting group and 19 had follicular reduction instead. This occurred between October 2010 and January 2011. Our main outcome was OHSS reduction.

Results:

Six (30%) women developed OHSS in the coasting group and 2 (10.5%) women developed OHSS in the follicular group (p-value=0.235). The pregnancy rates in the cycles were similar for both groups: 4/20 (20%) in the coasting group and 3/19 (15.8%) in the follicular group (p-value=1.000). The cancellation rate of the cycles was similar for both groups, 6/20 (30%) in the coasting group and 1/19 (5.3%) in the follicular group (p-value=0.09). The median number of punctured follicles was significantly lower in the follicular group (16 follicles, interquartile range (IQR)=21-12) compared to the coasting group (29 follicles, IQR=37.8-19.8, p-value=0.001). The retrieved, fertilized, and cleaved oocytes, as well as the number of embryos transferred, were similar amongst both groups.

Conclusion:

There was no difference between follicular reduction prior to HCG and coasting, in terms of OHSS reduction, pregnancy, and cancellation rates in both the IVF and ICSI cycles.

Is Coasting Valuable in All Patients with Any Cause of Infertility?

OBJECTIVES

This study aimed to assess the influence of coasting duration on the number and quality of oocytes and fertilization rate in male factor infertile women and those with polycystic ovary syndrome (PCOS).

METHODS

In this prospective observational follow-up study, 114 patients undergoing coasting (53 women with male factor infertility and 61 women with PCOS) were evaluated at the Royan Institute Research Center, Iran, between 2010 and 2012.

RESULTS

The results were analyzed according to the coasting periods of 1-4 days. In normal females, the number of oocytes retrieved was significantly reduced after the second day (p = 0.004). In addition, a statistically significant drop was observed in the number of metaphase II oocytes and fertilization rate after the third day (p = 0.006 and p = 0.006, respectively). No significant differences were observed in the number and quality of oocytes retrieved and fertilization rate with regard to coasting days in PCOS patients.

CONCLUSION

Coasting with duration of more than three days should be performed with caution in normal females who are at risk of developing ovarian hyperstimulation syndrome.

Microdose flare protocol with interrupted follicle stimulating hormone and added androgen for poor responders--an observational pilot study

OBJECTIVE

To investigate whether temporarily withholding FSH and adding androgen could improve follicular response during a microdose flare protocol in women with slow follicular growth or asynchronous follicular development.

DESIGN

Observational pilot study.

SETTING

University-affiliated private fertility center.

PATIENT(S)

Twenty-six women aged 34-47 years with poor response to stimulation or a previous cancelled IVF cycle and with slow or asynchronous follicular growth during a microdose flare cycle.

INTERVENTION(S)

For 13 women, after initiation of ovarian stimulation using the microdose flare protocol, gonadotropin administration was interrupted and transdermal testosterone gel was added for several days (4.4 ± 1.2 d) starting after cycle day 7 (mean cycle day 10 ± 2.6).

MAIN OUTCOME MEASURE(S)

FSH, E2, follicular growth, and total number of mature oocytes retrieved were determined for all of the patients. Cycle cancellation rate as well as pregnancy rate following embryo transfer were also documented when applicable.

RESULT(S)

FSH levels declined (25.2 ± 6.5 to 6.8 ± 3.2 IU/L), E2 levels increased (896 ± 687 to 2,163 ± 1,667 pmol/L), and follicular growth improved significantly during gonadotropin interruption and were tracked for 2 days during this time frame. The average number of oocytes retrieved was 5.3 ± 2.6, and the ratio of mature to total oocytes was 4:5. Four of the 13 women in the interruption group conceived following frozen embryo transfer, whereas none in the control group did.

CONCLUSION(S)

The androgen-interrupted FSH protocol may improve follicular response to gonadotropins in cycles that might otherwise be cancelled.

Does the serum E2 level change following coasting treatment strategy to prevent ovarian hyperstimulation syndrome impact cycle outcomes during controlled ovarian hyperstimulation and in vitro fertilization procedure?

OBJECTIVE

Ovarian hyperstimulation syndrome (OHSS) remains as a clinical problem for hyperresponder patients during controlled ovarian hyperstimulation and in vitro fertilization (COH-IVF) procedure. Herein, we aimed to evaluate the COH-IVF outcomes in hyperresponder patients managed with coasting treatment strategy for OHSS prevention regarding the establishment of clinical pregnancy as an endpoint of the treatment cycle.

MATERIALS AND METHODS

The medical records related to the COH-IVF outcome in 119 hyperresponder patients who have exhibited a serum estradiol level greater than or equal to 3000 pg/mL were evaluated. The study was conducted on a total of 119 patients, 98 of whom have been treated by coasting or coasting with GnRH antagonist co-treatment strategies, while the remaining 21 women (control group) have not been managed with coasting treatment. The COH and IVF-ET outcomes in the 119 patients were compared based on the coasting treatment situation.

RESULTS

Among the women who received coasting treatment, the number of patients demonstrating E2 level decrement and also E2 level decrement rate after coasting were similar between patients with and without clinical pregnancy. Total gonadotropin dose, 2PN number, embryo number, and fertilization rate were significantly higher in the patients with a clinical pregnancy.

CONCLUSION

The coasting treatment is a clinically useful preventive strategy for OHSS avoidance. GnRH antagonist co-treatment decreases the duration of coasting although any detrimental or ameliorating impact of this effect on pregnancy rates have not been seen. The E2 level decrement or increment following coasting treatment seems not to be related to cycle outcomes.

Minimum dose of hCG to trigger final oocyte maturation and prevent OHSS in a long GnRHa protocol

This paper was aimed to study the minimum dose of human chorionic gonadotropin (hCG) to effectively trigger maturation of oocytes and prevent ovarian hyperstimulation syndrome (OHSS) in a series of hyper-responders treated with a long gonadotropin releasing hormone agonist (GnRHa) protocol. Six women at high risk of developing severe OHSS in a long GnRHa protocol were enrolled into this study. Serum hormone levels on the day of and after hCG administration, antral follicle count, oocyte retrieval number and quality were determined. In total, 6 women aged between 29 and 36 years and at risk of developing severe OHSS, received 2000 U hCG. Five of them were treated with coasting for 1 day and the rest one for 4 days. The mean number of oocytes collected was 19 (range 14-27) and the fertilization rate per collected oocyte was 72.81%. Of the 6 women in the study, only one cancelled embryos transfer and all embryos were frozen, and then she delivered two health boys on term in the subsequent frozen-thawed embryo transfer (FET) cycle. Pregnancies and births were achieved in 3 patients out of 5 in vitro fertilization-embryo transfer (IVF-ET) cycles. No woman developed moderate or severe OHSS. Triggering with 2000 U hCG is feasible to prevent OHSS in unpredicted hyper-responders undergoing IVF in a long GnRHa protocol.

Ovarian hyperstimulation syndrome: pathophysiology and prevention

PURPOSE

To review and discuss the pathophysiology and prevention strategies for ovarian hyperstimulation syndrome (OHSS), which is a condition that may occur in up to 20% of the high risk women submitted to assisted reproductive technology cycles.

METHODS

The English language literature on these topics were reviewed through PubMed and discussed with emphasis on recent data.

RESULTS

The role of estradiol, luteinizing hormone, human chorionic gonadotropin (hCG), inflammatory mediators, the renin-angiotensin system and vascular endothelial growth factor is discussed in the pathophysiology of OHSS. In addition we consider the prevention strategies, including coasting, administration of albumin, renin-angiotensin system blockage, dopamine agonist administration, non-steroidal anti-inflammatory administration, GnRH antagonist protocols, reducing hCG dosage, replacement of hCG and in vitro maturation of oocytes (IVM).

CONCLUSIONS

Among the many prevention strategies that have been discussed, the current evidence points to the replacement of hCG by GnRH agonists in antagonist cycles and the performance of IVM procedures as the safest approaches.

A unique human chorionic gonadotropin antagonist suppresses ovarian hyperstimulation syndrome in rats

Ovarian hyperstimulation syndrome (OHSS) is a complication of in vitro fertilization associated with physiological changes after hCG administration to induce final oocyte maturation. It presents as widespread increases in vascular permeability and, in rare cases, results in cycle cancellation, multi-organ dysfunction, and pregnancy termination. These physiological changes are due primarily to activation of the vascular endothelial growth factor (VEGF) system in response to exogenous human chorionic gonadotropin (hCG). An hCG antagonist (hCG-Ant) could attenuate these effects by competitively binding to the LH/CG receptor, thereby blocking LH activity in vivo. We expressed a form of hCG that lacks three of its four N-linked glycosylation sites and tested its efficacy as an antagonist. The hCG-Ant binds the LH receptor with an affinity similar to native hCG and inhibits cAMP response in vitro. In a rat model for ovarian stimulation, hCG-Ant dramatically reduces ovulation and steroid hormone production. In a well-established rat OHSS model, vascular permeability and vascular endothelial growth factor (VEGF) expression are dramatically reduced after hCG-Ant treatment. Finally, hCG-Ant does not appear to alter blastocyst development when given after hCG in mice. These studies demonstrate that removing specific glycosylation sites on native hCG can produce an hCG-Ant that is capable of binding without activating the LH receptor and blocking the actions of hCG. Thus hCG-Ant will be investigated as a potential therapy for OHSS.

Does coasting, a procedure to avoid ovarian hyperstimulation syndrome, affect assisted reproduction cycle outcome?

OBJECTIVE

To evaluate the effects of coasting (withdrawing gonadotropin administration) on IVF outcome.

DESIGN

Retrospective study.

SETTING

Department of Infertility of Zekai Tahir Burak Women's Health Research and Education Hospital.

PATIENT(S)

Ninety-four patients in whom coasting was applied (group 1). One control group consisted of 22 patients in whom coasting was not applied despite E(2) > 3000 pg/mL (group 2). A control group consisted of 111 normally responsive patients with peak E(2) < 3000 pg/mL level (group 3).

INTERVENTION(S)

When E(2) levels were greater than 3000 pg/mL in the presence of at least 20 follicles, each measuring >or=10 mm in diameter with >or=20% of them of diameter >or=15 mm, recombinant FSH administration was discontinued while GnRH agonist was maintained.

MAIN OUTCOME MEASURE(S)

Hormonal characteristics, IVF outcome, OHSS in coasted and noncoasted groups.

RESULT(S)

There was no statistically significant difference between number of total oocytes retrieved, metaphase II oocytes, and fertilization rates among the group 1 vs. group 2. However, the implantation rates and pregnancy rates were significantly higher in group 1 compared with group 2. Group 1 had more total oocytes retrieved and metaphase II oocytes compared with group 3. However, there was no significant difference in implantation and pregnancy rates between groups 1 and 3.

CONCLUSION(S)

Coasting does not adversely affect assisted reproductive technology outcome and can be applied safely to high responder patients in ICSI.

Ovarian hyperstimulation syndrome: steps to maximize success and minimize effect for assisted reproductive outcome

OBJECTIVE

To investigate the strategies used to decrease the risk of ovarian hyperstimulation syndrome (OHSS) and their impact on pregnancy and live birth rates.

DESIGN

Retrospective cohort analysis.

SETTING

University hospital.

PATIENT(S)

One hundred eighty-eight patients undergoing fresh in vitro fertilization (IVF) cycles between 2000 and 2004, with peak serum estradiol levels >2500 pg/mL and presumed to be at risk for OHSS.

INTERVENTION(S)

Coasting and elective embryo cryopreservation were evaluated for their effect on OHSS and live birth rates.

MAIN OUTCOME MEASURE(S)

Pregnancy, live birth rates, and OHSS incidence.

RESULT(S)

Out of 188 patients at risk for OHSS, 21 patients had their cycles coasted (group 1), and elective embryo cryopreservation was performed in 32 patients (group 2). In 135 patients with no other risk factors, ovulation was triggered with human chorionic gonadotropin and embryo transfer was performed (group 3). The incidence in our IVF population was 38 out of 1002 (3.8%). The overall incidence of OHSS for those who had an estradiol level >2500 pg/mL was 20.2% (38 out of 188), and none of the patients in group 1 developed OHSS; 13 out of 32 patients in group 2 (40.6%) and 25 out of 135 (18.5%) patients in group 3 developed OHSS. The live birth rate was 38%, 40%, and 45% in groups 1, 2, and 3, respectively, and the cumulative live birth rate was 52%, 75%, and 59%, respectively.

CONCLUSION(S)

Elective cryopreservation of embryos with subsequent frozen embryo transfer and coasting are effective ways of maximizing pregnancy and limiting severe OHSS.