Impact of endometrial preparation on early pregnancy loss and live birth rate after frozen embryo transfer: a large multicenter cohort study (14,421 frozen cycles)

STUDY QUESTION

Does the endometrial preparation protocol (artificial cycle (AC) vs natural cycle (NC) vs stimulated cycle (SC)) impact the risk of early pregnancy loss and live birth rate after frozen/thawed embryo transfer (FET)?

SUMMARY ANSWER

In FET, ACs were significantly associated with a higher pregnancy loss rate and a lower live birth rate compared with SC or NC.

WHAT IS KNOWN ALREADY

To date, there is no consensus on the optimal endometrial preparation in terms of outcomes. Although some studies have reported a higher pregnancy loss rate using AC compared with NC or SC, no significant difference was found concerning the pregnancy rate or live birth rate. Furthermore, no study has compared the three protocols in a large population.

STUDY DESIGN, SIZE, DURATION

A multicenter retrospective cohort study was conducted in nine reproductive health units in France using the same software to record medical files between 1 January 2012 and 31 December 2016. FET using endometrial preparation by AC, modified NC or SC were included. The primary outcome was the pregnancy loss rate at 10 weeks of gestation. The sample size required was calculated to detect an increase of 5% in the pregnancy loss rate (21–26%), with an alpha risk of 0.5 and a power of 0.8. We calculated that 1126 pregnancies were needed in each group, i.e. 3378 in total.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Data were collected by automatic extraction using the same protocol. All consecutive autologous FET cycles were included: 14 421 cycles (AC: n = 8139; NC: n = 3126; SC: n = 3156) corresponding to 3844 pregnancies (hCG > 100 IU/l) (AC: n = 2214; NC: n = 812; SC: n = 818). Each center completed an online questionnaire describing its routine practice for FET, particularly the reason for choosing one protocol over another.

MAIN RESULTS AND THE ROLE OF CHANCE

AC represented 56.5% of FET cycles. Mean age of women was 33.5 (SD ± 4.3) years. The mean number of embryos transferred was 1.5 (±0.5). Groups were comparable, except for history of ovulation disorders (P = 0.01) and prior delivery (P = 0.03), which were significantly higher with AC. Overall, the early pregnancy loss rate was 31.5% (AC: 36.5%; NC: 25.6%; SC: 23.6%). Univariable analysis showed a significant association between early pregnancy loss rate and age >38 years, history of early pregnancy loss, ovulation disorders and duration of cryopreservation >6 months. After adjustment (multivariable regression), the early pregnancy loss rate remained significantly higher in AC vs NC (odds ratio (OR) 1.63 (95% CI) [1.35–1.97]; P < 0.0001) and in AC vs SC (OR 1.87 [1.55–2.26]; P < 0.0001). The biochemical pregnancy rate (hCG > 10 and lower than 100 IU/l) was comparable between the three protocols: 10.7% per transfer.

LIMITATIONS, REASONS FOR CAUTION

This study is limited by its retrospective design that generates missing data. Routine practice within centers was heterogeneous. However, luteal phase support and timing of embryo transfer were similar in AC. Univariable analysis showed no difference between centers. Moreover, a large number of parameters were included in the analysis.

WIDER IMPLICATIONS OF THE FINDINGS

Our study shows a significant increase in early pregnancy loss when using AC for endometrial preparation before FET. These results suggest either a larger use of NC or SC, or an improvement of AC by individualizing hormone replacement therapy for patients in order to avoid an excess of pregnancy losses.

STUDY FUNDING/COMPETING INTEREST(S)

The authors declare no conflicts of interest in relation to this work. G.P.-B. declares consulting fees from Ferring, Gedeon-Richter, Merck KGaA, Theramex, Teva; Speaker’s fees or equivalent from Merck KGaA, Ferring, Gedeon-Richter, Theramex, Teva. N.C. declares consulting fees from Ferring, Merck KGaA, Theramex, Teva; Speaker’s fees or equivalent from Merck KGaA, Ferring. C.R. declares a research grant from Ferring, Gedeon-Richter; consulting fees from Gedeon-Richter, Merck KGaA; Speaker’s fees or equivalent from Merck KGaA, Ferring, Gedeon-Richter; E.M.d’A. declares Speaker’s fees or equivalent from Merck KGaA, MSD, Ferring, Gedeon-Richter, Theramex, Teva. I.C-D. declares Speaker’s fees or equivalent from Merck KGaA, MSD, Ferring, Gedeon-Richter, IBSA. N.M. declares a research grant from Merck KGaA, MSD, IBSA; consulting fees from MSD, Ferring, Gedeon-Richter, Merck KGaA; Speaker’s fees or equivalent from Merck KGaA, MSD, Ferring, Gedeon-Richter, Teva, Goodlife, General Electrics.

TRIAL REGISTRATION NUMBER

N/A.

IVF outcomes in patients with a history of bariatric surgery: a multicenter retrospective cohort study

STUDY QUESTION

How does a history of dramatic weight loss linked to bariatric surgery impact IVF outcomes?

SUMMARY ANSWER

Women with a history of bariatric surgery who had undergone IVF had a comparable cumulative live birth rate (CLBR) to non-operated patients of the same BMI after the first IVF cycle.

WHAT IS KNOWN ALREADY

In the current context of increasing prevalence of obesity in women of reproductive age, weight loss induced by bariatric surgery has been shown to improve spontaneous fertility in obese women. However, little is known on the clinical benefit of bariatric surgery in obese infertile women undergoing IVF.

STUDY DESIGN, SIZE, DURATION

This exploratory retrospective multicenter cohort study was conducted in 10 287 IVF/ICSI cycles performed between 2012 and 2016. We compared the outcome of the first IVF cycle in women with a history of bariatric surgery to two age-matched groups composed of non-operated women matched on the post-operative BMI of cases, and non-operated severely obese women.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The three exposure groups of age-matched women undergoing their first IVF cycle were compared: Group 1: 83 women with a history of bariatric surgery (exposure, mean BMI 28.9 kg/m2); Group 2: 166 non-operated women (non-exposed to bariatric surgery, mean BMI = 28.8 kg/m2) with a similar BMI to Group 1 at the time of IVF treatment; and Group 3: 83 non-operated severely obese women (non-exposed to bariatric surgery, mean BMI = 37.7 kg/m2). The main outcome measure was the CLBR. Secondary outcomes were the number of mature oocytes retrieved and embryos obtained, implantation and miscarriage rates, live birth rate per transfer as well as birthweight.

MAIN RESULTS AND THE ROLE OF CHANCE

No significant difference in CLBR between the operated Group 1 patients and the two non-operated Groups 2 and 3 was observed (22.9%, 25.9%, and 12.0%, in Groups 1, 2 and 3, respectively). No significant difference in average number of mature oocytes and embryos obtained was observed among the three groups. The implantation rates were not different between Groups 1 and 2 (13.8% versus 13.7%), and although lower (6.9%) in obese women of Group 3, this difference was not statistically significant. Miscarriage rates in Groups 1, 2 and 3 were 38.7%, 35.8% and 56.5%, respectively (P = 0.256). Live birth rate per transfer in obese patients was significantly lower compared to the other two groups (20%, 18%, 9.3%, respectively, in Groups 1, 2 and 3, P = 0.0167). Multivariate analysis revealed that a 1-unit lower BMI increased the chances of live birth by 9%. In operated women, a significantly smaller weight for gestational age was observed in newborns of Group 1 compared to Group 3 (P = 0.04).

LIMITATIONS, REASONS FOR CAUTION

This study was conducted in France and nearly all patients were Caucasian, questioning the generalizability of the results in other countries and ethnicities. Moreover, 950 women per group would be needed to achieve a properly powered study in order to detect a significant improvement in live birth rate after bariatric surgery as compared to infertile obese women.

WIDER IMPLICATIONS OF THE FINDINGS

These data fuel the debate on the importance of pluridisciplinary care of infertile obese women, and advocate for further discussion on whether bariatric surgery should be proposed in severely obese infertile women before IVF. However, in light of the present results, infertile women with a history of bariatric surgery can be reassured that surgery-induced dramatic weight loss has no significant impact on IVF prognosis.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by unrestricted grants from FINOX-Gédéon Richter and FERRING Pharmaceuticals awarded to the ART center of the Clinique Mathilde to fund the data collection and the statistical analysis. There are no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

NCT02884258.

[Progesterone and frozen-thawed embryo transfer after hormonal replacement therapy for endometrial preparation: An update on medical practices]

Frozen-thawed embryo transfer (FET) has recently become the most frequently performed ART procedure. Many protocols for endometrial preparation are used, without any evidence-based superiority of one protocol above the others. Most French fertility centers mainly use hormonal replacement treatment (HRT) for endometrial preparation for organizational reasons. According to some studies, early pregnancy losses rate is higher with HRT endometrial preparation for FET than with other protocols, leading to new insights in improving outcomes into ART centers. There is a lack of consensual guidelines regarding the use of HRT for FET: there are various protocols, with different dosages, duration and routes for progesterone (PG) prescription. To date, the vaginal route is the most popular around the world as it gives higher intra-uterine concentration of PG because of the first uterine pass. However, recent scientific publications have pointed the importance of PG measurement in order to detect a lack of PG supplementation. Whatever the route of administration, it seems that a significant proportion of patients do not reach adequate PG concentrations for successful implantation and ongoing pregnancy. Timing of the measurement and ideal serum PG rate to reach are yet to be defined. What treatment strategy to adopt according to the results is still under investigation. Individualization of PG doses and routes of administration could lead to a decrease in miscarriages and better outcome.

[Dual trigger with gonadotropin-releasing hormone agonist and hCG to improve oocyte maturation rate]

OBJECTIVE

This study investigates dual trigger with GnRHa and hCG as a potential treatment in patients with a history of ≥25 % immature oocytes retrieved in IVF/ICSI cycles.

METHODS

This is a retrospective case-control study performed between October 2008 and December 2017. Forty-seven patients who experienced high oocyte immaturity rate (≥25 %) during their first IVF/ICSI cycle (analyzed as control group) and received a dual trigger for their subsequent cycle, were involved. During dual trigger cycles, patients received antagonist protocol and ovulation triggering using triptorelin 0.2mg and hCG. Primary endpoint was maturation rate (MR). Secondary endpoints were fertilization, D2 top quality embryo (TQE) rates, clinical pregnancy rate per fresh embryo transfer and cumulative clinical pregnancy rate per couple.

RESULTS

A significant increase in MR was achieved in case of dual trigger (71.0 %) when compared to control group (47.8 %; P<0.0001). Moreover, cumulative clinical pregnancy rate yielded 46.8 % in dual trigger group, which was statistically higher than 27.6 % obtained in control group (P=0.05). However, fertilization, D2 TQE rates and clinical pregnancy rates/transfer were statistically similar when compared between the two groups.

CONCLUSION

Dual trigger seems efficient for managing patients with high oocyte immaturity rate.

[Embryo development in two single-step media: Analysis of 2059 sibling oocytes]

OBJECTIVE

The aim of this study was to compare embryo development cultured in two single-step media commercially available: Fert/Sage One Step® (Origio) and Continuous Single Culture® (CSC) (Irvine Scientific).

METHODS

A prospective auto-controlled study of sibling oocytes from women undergoing conventional in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) was performed in our center from February to June 2015. After fertilization, for every patient, half of oocytes were cultured in the single-step Fert/Sage One Step® (serie SAGE) and the other half in the single-step CSC®(serie CSC). Fertilization and embryo morphology rates were assessed by day 1 to day 5-6 if needed. Embryo presenting<20% of fragmentation and 4 cells at day 2, 8 cells at day 3 were qualified as "top quality". Embryo with<20% of fragmentation and 3-5 cells at day 2, 6-10 cells at day 3 were qualified as "good quality". Blastocyst B3, B4, B5 with A or B inner cell mass and A or B trophectoderm were qualified as "good quality". Transferred or frozen embryos were qualified as useful embryos.

RESULTS

Sixty-two attempts of IVF and 133 of ICSI were analyzed, corresponding to 2059 inseminated or micro-injected oocytes. Fertilization rate were not different between the 2 series, respectively SAGE vs CSC (IVF: 73.4% vs 68.3% [P=0.49]; ICSI: 58.9% vs 63.8% [P=0.12]). No difference was found for embryo morphology, respectively SAGE vs CSC, at day 2 (top quality embryo at day 2 IVF: 34.4% vs 33% [P=0.98]; ICSI: 42.4% vs 44.9% [P=0.37]; and good quality embryo at day 2 IVF: 44% vs 50.2% [P=0.07]; ICSI: 64% vs 71% [P=0.35]); no difference at day 3 (top quality embryo at day 3 IVF: 19.4% vs 21.3% [P=0.61]; ICSI: 28.7% vs 27.4% [P=0.54]; and good quality embryo at day 3 IVF: 40.4% vs 50.2% [P=0.91]; ICSI: 51% vs 47.6% [P=0.47]). Blastocyst development rate were not different, respectively SAGE vs CSC (IVF: 39.9% vs 41.5% [P=0.63] with 42.9% vs 42.2% of good quality blastocyst [P=0.70]; ICSI: 41.1% vs 37.8% [P=0.18] with 32.9% vs 40.8% of good quality blastocyst [P=0.13]). No difference was found in the useful embryo rate in the 2 series SAGE vs CSC (IVF: 52.8% vs 55.2% [P=0.83]; ICSI: 62.4% vs 61.7% [P=0.70]).

CONCLUSION

Embryo development and rate of useful embryos, transferred or frozen, were not different according to the embryo culture in single-step media Fert/Sage One Step® vs single-step Continuous Single Culture®.

[Impact of polycystic ovary syndrome on oocyte and embryo quality]

This review analyzes the literature concerning oocyte and embryo quality, in case of in vitro fertilization (IVF) for women with polycystic ovary syndrome (PCOS). Alterations in oocyte quality, and consequently in embryo quality, may be due to endocrine and intra-ovarian paracrine changes. However, most of publications find similar biological and clinical results after IVF, with or without microinjection, for women with PCOS compared to those obtained in control populations. Subgroups of more pejorative outcome probably exist within PCOS population. Finally, obesity, which is frequent in PCOS, is clearly deleterious, and multidisciplinary care, including lifestyle modifications, is then needed.

[Outcome of embryo vitrification compared to slow freezing process at early cleavage stages. Report of the first French birth]

OBJECTIVES

Since the end of 2010, France by "l'Agence de Biomédecine" has validated the embryo vitrification procedure as an improvement of the slow freezing method. We presented here data concerning biological and clinical outcomes from a prospective observational study where early cleavage stage good quality embryos were vitrified and warmed. We compared these results to those of a retrospective series where embryos were thawed after a slow freezing procedure (SF). We report also the first French live birth following embryo vitrification.

PATIENTS AND METHODS

In all, 58 cycles of frozen-thawed embryo transfers (FET) following vitrification were prospectively included and compared with 189 FET from SF method. Primary end points were the (i) survival rate (SR) (% of embryos with ≥50% post-thaw intact blastomeres), (ii) intact survival rate (ISR) (% of embryos with 100% post-thaw intact blastomeres) and (iii) survival blastomeres index (SBI) (% of post thaw intact blastomeres per survival embryo). Secondary end point was the clinical pregnancy rate (CPR) defined as the presence of an intra-uterine gestational sac with positive foetal heart beat. We report here the first French live birth following embryo vitrification.

RESULTS

In all, 87 and 412 embryos have been thawed following vitrification and SF, respectively. We observed a highly significant increase of SR, ISR et SBI respectively when thawing concerned vitrified embryos rather than those from SF method (98.3±13.1% vs. 77.3±32.0%, P<10(-4); 88.2±28.3% vs. 47.7±41.4%, P<10(-4); 97.7±6.1% vs. 87.3±14.4%, P<10(-4)). Furthermore, CPR were of 32.7% (19/58) and of 18.5% (35/189) following FET performed after vitrification or SF and thawing (P=0.03), respectively. The live birth of two healthy girls occurred following a caesarean section after 38 weeks of amenorrhea the 8th of August 2011.

DISCUSSION AND CONCLUSION

We experienced in our study that the post-thaw survival of vitrified embryos was significantly better than those of embryos resulting from SF. Then, a better CPR per thawed embryo cycle was observed following vitrification.

[Fertility after endometrial osseous metaplasia elective hysteroscopic resection]

OBJECTIVES

The endometrial osseous metaplasia is a rare disease which is characterized by the presence of osseous tissue in endometrium. It is often diagnosed in women with secondary infertility. The main objective of this work is to evaluate fertility after elective resection of osteoid metaplasia endometrial lesions by operative hysteroscopy in infertile women.

PATIENTS AND METHOD

Retrospective and descriptive series of 7 cases observed in the Woman and Child department, CHU Jean-Verdier. The 7 women were in reproductive age, of African origin, with secondary infertility after abortions concerning 6 out of the 7 patients.

RESULTS

In all cases, endovaginal pelvic ultrasound has raised endometrial calcification, and diagnostic hysteroscopy highlighted endometrial osteoid metaplasia. The operative hysteroscopic procedure consisted of elective diathermic resection to handle endometrial insertion of bone chips. A second diagnostic hysteroscopy was systematically done. It showed no recurrence. Six of the 7 patients began pregnancy, 3 spontaneously and 3 after IVF/ICSI in the first year following the hysteroscopic treatment. The evolution of pregnancies has been marked by 2 normal deliveries, 1 spontaneous miscarriage and then an ectopic pregnancy in one patient, 1 growth retardation intrauterine requiring caesarean at 38 SA, 1 HELLP syndrome in a twin pregnancy requiring ceasarean at 27 SA followed normal labor at term and 1 pregnancy lost sight.

DISCUSSION AND CONCLUSION

Hysteroscopic elective resection seems to be the treatment of choice with a good prognosis on subsequent fertility.

[Predictive factors of success in ovulation induction with recombinant FSH: results of Indigo study]

INTRODUCTION

Although ovulation induction is commonly used to treat infertility, few data are available concerning this treatment. Therefore, the aim of this prospective observational study was to describe medical practices and to identify predictive outcome factors of ovarian stimulation by recombinant FSH (r-hFSH), administrated with a self-injector pen.

PATIENTS AND METHODS

At the time of the prescription of ovarian stimulation followed by sexual intercourse (SI) or artificial insemination (HAI) with a normal husband sperm, 370 gynaecologists consecutively sent from January to November 2005, for a maximum of six patients (1398 patients in total), a form dealing with the assessment of infertility factors prior to stimulation (n=1340), then a monitoring form of the treated cycle (n=1227) and when a pregnancy was obtained, a follow-up form at 12 weeks of amenorrhea (n=254). Each patient had to complete an autoquestionnaire about the use of the pen (n=1044).

RESULTS

Seventy percent of the contributing gynaecologists had only a private practice. The mean age of patients was 31.9+/-4.8 years. Dealing with infertility exploration prior to stimulation, 9% did not have tubal assessment. Although it was the first stimulation attempt for 52% of cases, 91% of patients found the pen easy to manipulate. The mean duration of r-hFSH administration was 8.8+/-3.7 days and the mean daily dose was 75.4+/-29.4 IU. Ultrasound and hormonal monitoring was performed for 88% of patients. The cycle cancellation rate was 11%. The hCG administration was performed on cycle day 13+/-3. An HAI was programmed in 60% of patients and SI in 40%. The pregnancy rates for positive betahCG, ongoing and multiple pregnancies were, respectively, 22.7, 18 and 16% (twins 14%; 2% of triplets or more 2%). Three prognosis factors were independently related to ongoing pregnancy rate: age<35 years, previous pregnancy obtained by treatment and presence of ovulatory disorders.

DISCUSSION AND CONCLUSION

This observatory of ovarian stimulation out of FIV allowed to describe medical practices of gynaecologists: infertility assessment prior to ovarian stimulation, used FSH doses, ultrasound and hormonal monitoring, and it outlined three predictive factors of outcome: age, previous pregnancy obtained by treatment and presence of ovulatory disorders.

[Views of each member of an Assisted Reproductive Technologies centre on the embryo transfer procedure]

The embryo transfer (ET) is probably the key step of Assisted Reproductive Technologies (ART), end point of the collaboration of a multidisciplinary clinical team and an infertile couple. Thus, a perfect knowledge of available data regarding ET is required to optimize the results of ART. Indeed, numerous published studies demonstrate the impact of defined parameters onto the effectiveness of ET procedure. The aim of this study is to provide views of physicians dealing with ART, i.e. endocrinologist, ultrasound scan specialist, surgeon and biologist to put in perspective questions and answers about ET.

[Prospective evaluation of elective single-embryo transfer versus double-embryo transfer following in vitro fertilization: a two-year French hospital experience]

OBJECTIVE

Multiple embryo transfer is responsible for a high rate of multiple pregnancies (ICSI), with subsequent risks of premature birth and perinatal death. This prospective non randomized study aimed to assess the ability of an elective single-embryo transfer (eSET) policy to reduce the twin pregnancy rate, compared to a double embryo transfer (DET) approach.

PATIENTS AND METHODS

Between March 2005 and May 2006, 180 eligible women were proposed to benefit from an eSET transfer rather than a DET. Inclusion criteria were (i) age less than 37 years old; (ii) at least two good quality embryos available (three to five cells at day 2 or six to nine cells at day 3; less than 20% fragmentation and the absence of multinucleates blastomeres), after IVF or ICSI and (iii) no more than one previous failed treatment cycle. Outcome analysis included cycles with frozen-thawed embryo transfer (FET).

RESULTS

According to patients' decision, 107 and 73 women had an eSET (59.4%) and a DET (40.6%) respectively. No differences were found between eSET and DET groups regarding demographics and biologicals parameters. The clinical pregnancy rate (PR) per transfer was 43.9% in eSET group and 57.5% in DET group (p=0.07). The twin pregnancy rates were 0 and 14.3%, in eSET and DET groups, respectively (p=0.007). The cumulative PR per patient, including the outcome of performed FET cycles, was 63.6% in eSET group and 61.6% in DET group. In this case, the cumulative twin pregnancy rates were 2.9 and 15.6% in eSET and DET groups, respectively (p=0.02).

DISCUSSION AND CONCLUSION

Our data show that in a selected population of women, transferring one fresh embryo and then, if required, one or two frozen-thawed embryos significantly reduces the twin pregnancy rate without decreasing the overall pregnancy rate. This study supports the policy of eSET in this subgroup of patients.

[Hypothyroidism: from the desire for pregnancy to delivery]

The link between hypothyroidism and infertility is still a matter of debate. Hypothyroidism can result in cycle disturbances, such as oligomennorhea and functional bleeding. Additionally, several studies have shown that thyroid autoimmunity (detection of anti peroxydase antibodies) may account for the occurrence of repetitive miscarriages. In infertility work-up, screening thyroid function should be specifically recommended for women with clinical hypothyroidism, with a personal, familial history of thyroid or other auto immune diseases (such as type I diabetes) as well as for women with unexplained anovulation or functional bleeding. Moreover, detection of thyroid antibody seems to be worthwhile for the assessment of recurrent miscarriages, due to the potential benefit of thyroid supplementation. In pregnant women, assessment of thyroid function seems specifically crucial to ensure adequate foetal development. Indeed, it has been well established that untreated maternal hypothyroidism may be associated with disturbances of brain development and low intellectual quotient. Additionally, other foetal (growth deficiency, premature birth, low birth weight) as well as maternal (gestational hypertension, pre-eclampsia...) complications have been also reported in pregnant women with untreated hypothyroidism. Consequently, screening of thyroid function should be performed in every woman at risk of thyroid disease. Recent studies even advocate that thyroid screening should be extended to the overall pregnant population. The objective is to adjust L-thyroxin supplementation to maintain serum TSH concentrations below the threshold of 2.5 mUI/l. Finally, iodine deficiency, currently observed in pregnant women, should be prevented by iodine supply prior to conception, during pregnancy and during breast feeding as well.

[Follicle-stimulating hormone receptor polymorphism and ovarian function]

The FSH receptor presents several polymorphisms. Two of them, located at codon 307 and 680, are the most frequent. Threonine can be substituted by alanine at position 307 and serine can be substituted by asparagine at position 680. The two most frequent allelic combinations are Thr(307) -Asn (680) (60%) and Ala(307) -Ser (680) (40%). As the allelic variants at codon 307 and 680 are almost invariably associated, most of the studies assessed only one codon (680) and classified the women as homozygous (Ser/Ser ou Asn/Asn) or heterozygous (Asn/Ser). Several studies aimed to correlate the follicle-stimulating hormone receptor polymorphism and ovarian function. Women homozygous for the Ser (680) variant have higher follicular FSH levels and longer follicular phase length, which suggest a lower sensitivity to FSH. The FSH receptor genotype would also influence the sensitivity to exogenous FSH: as regards ovarian stimulation, higher recombinant FSH doses are needed for Ser/Ser homozygous women. The analysis of polymorphism in women with premature ovarian failure did not show a link with any particular allelic variant. In women with polycystic ovaries, the distribution of the allelic variants greatly varies from one study to another.

The use of a decremental dose regimen in patients treated with a chronic low-dose step-up protocol for WHO Group II anovulation: a prospective randomized multicentre study

BACKGROUND

In women with chronic anovulation, the choice of the FSH starting dose and the modality of subsequent dose adjustments are critical in controlling the risk of overstimulation. The aim of this prospective randomized study was to assess the efficacy and safety of a decremental FSH dose regimen applied once the leading follicle was 10-13 mm in diameter in women treated for WHO Group II anovulation according to a chronic low-dose (CLD; 75 IU FSH for 14 days with 37.5 IU increment) step-up protocol.

METHODS

Two hundred and nine subfertile women were treated with recombinant human FSH (r-hFSH) (Gonal-f) for ovulation induction according to a CLD step-up regimen. When the leading follicle reached a diameter of 10-13 mm, 158 participants were randomized by means of a computer-generated list to receive either the same FSH dose required to achieve the threshold for follicular development (CLD regimen) or half of this FSH dose [sequential (SQ) regimen]. HCG was administered only if not more than three follicles >or=16 mm in diameter were present and/or serum estradiol (E(2)) values were <1200 pg/ml. The primary outcome measure was the number of follicles >or=16 mm in size at the time of hCG administration.

RESULTS

Clinical characteristics and ovarian parameters at the time of randomization were similar in the two groups. Both CLD and SQ protocols achieved similar follicular growth as regards the total number of follicles and medium-sized or mature follicles (>/=16 mm: 1.5 +/- 0.9 versus 1.4 +/- 0.7, respectively). Furthermore, serum E(2) levels were equivalent in the two groups at the time of hCG administration (441 +/- 360 versus 425 +/- 480 pg/ml for CLD and SQ protocols, respectively). The rate of mono-follicular development was identical as well as the percentage of patients who ovulated and achieved pregnancy.

CONCLUSIONS

The results show that the CLD step-up regimen for FSH administration is efficacious and safe for promoting mono-follicular ovulation in women with WHO Group II anovulation. This study confirms that maintaining the same FSH starting dose for 14 days before increasing the dose in step-up regimen is critical to adequately control the risk of over-response. Strict application of CLD regimen should be recommended in women with WHO Group II anovulation.

Effects of oral contraceptive, synthetic progestogen or natural estrogen pre-treatments on the hormonal profile and the antral follicle cohort before GnRH antagonist protocol

BACKGROUND

Steroid pre-treatments may be useful to program GnRH antagonist IVF/ICSI cycles. This prospective study assessed hormonal and ultrasound data collected during the free period after the discontinuation of three different pre-treatments to provide information on the optimal time interval required before starting stimulation.

METHODS

Women were randomized to receive oral contraceptive pill (OCP) [ethinyl estradiol (E(2)) 30 microg + desogestrel 150 microg] (n = 21) or norethisterone 10 mg/day (n = 23) or 17-betaE(2) 4 mg/day (n = 25) or no pre-treatment (n = 24) for one cycle before IVF. Assessments were performed on post-treatment day (PD) 1, 3 and 5, or on spontaneous cycle day (CD) 1 and 3.

RESULTS

After OCP and progestogen administration, FSH and LH concentrations shifted from strongly suppressed PD1 levels to PD5 values similar to those observed on CD1. Meanwhile, follicle sizes remained small up to PD5. In contrast, estrogen pre-treatment poorly reduced FSH levels on PD1 compared with OCP or progestogen. Consequently, follicle size was more heterogeneous. FSH rebound was maximal on PD3, whereas LH levels were slightly increased up to PD5.

CONCLUSIONS

A 5-day free interval after OCP or progestogen offers the advantages of gonadotrophin recovery and homogeneous follicular cohort, whereas early FSH rebound occurring after estrogen pre-treatment argues for a short free period.

Hyperstimulation ovarienne : place de la chirurgie

Ovarian hyperstimulation syndrome is a iatrogenic complication that could happen during ovulation induction. Metabolic modifications can lead to a third sector and organic failure. Medical treatment, undertaken in first line, may be insufficient. In these cases, invasive treatment, using surgical techniques, in association with reanimation principles becomes necessary. From the simple drainage to final measures for the patient's rescue, this review describes the different solutions and their respective place. Several means exist, but serious evaluation is lacking. Their use should be indicated specifically. Medico-surgical associations seemed to offer interesting results.

[Intrauterine insemination: spontaneous or medically-assisted ovulation?]

Intrauterine insemination (i.u.i.) is usually proposed as the first-line therapy for infertility related to cervical factor, male and unexplained infertility. The overall success rate of i.u.i. is about 10-20% clinical pregnancies per cycle. i.u.i. may be performed in patients with or without prior controlled ovarian hyperstimulation (COH). The aim of COH is to closely monitor follicular growth in order to achieve a timely triggering of ovulation and i.u.i. Additionally, ovarian stimulation allows to increase the number of developing follicles. According to the review of previous prospective randomized studies and meta-analyses, it seems that: (i) when a cervical factor is involved, the advantage of COH in conjunction with i.u.i. is likely but has to be confirmed; (ii) in male infertility, COH with gonadotropins in conjunction with i.u.i. increases the clinical pregnancy rate by two. In this situation, the better the sperm parameters are, the more advantageous COH is; (iii) in unexplained infertility, COH in addition to i.u.i. improves the pregnancy rate but stimulation with clomifene citrate appears to be less effective than gonadotropins administration. Beside the sperm parameters, the success rate depends on both woman's age and degree of ovarian stimulation. Meanwhile, ovarian hyperstimulation exposes to the risk of multiple pregnancy and hyperstimulation syndrome. Increasing the number of preovulatory follicles from one to two allows to approximately double the pregnancy rate. However, there is clear evidence that getting three or more than three follicles exposes to a worrying risk of multiple pregnancy. At the present time, the successful outcome of i.u.i. should not be assessed by the clinical pregnancy rate any longer but by the singleton birth rate. Our therapeutic strategy for COH prior to i.u.i. should take into account woman's age, infertility duration and associated infertility factors. The objective in terms of preovulatory follicle number must be determined prior to the stimulation in order to optimise the cycle outcome with a singleton birth.

[Antagonist protocols: residual LH levels and the value of exogenous LH supplementation]

When administered in the late follicular phase to prevent any LH surge, GnRH antagonists induce a sharp decrease in serum LH levels that may be detrimental for assisted reproductive technology cycle outcome. This decrease in LH levels is dose-dependant. Supplementation with recombinant LH when introducing GnRH antagonist leads to significant changes in E2 secretion. This is consistent with a key role of LH to ensure adequate steroidogenesis. This also indicates that a single dose of GnRH antagonist is able to decrease bioactive LH below a minimal threshold for optimal steroidogenesis. However, supplementation with rLH does not modify the number of retrieved oocytes, obtained embryos and the pregnancy rate. This is in line with the concept that folliculogenesis is mainly dependent on FSH and that the role of LH and E2 is not primordial. Indeed, the findings of our prospective randomized study do not support a systematic supplementation with rLH when introducing antagonist. However, further studies are necessary to determine whether a specific sub group of patients characterized by a low E2/oocyte ratio could benefit from rLH supplementation.

Recombinant human LH supplementation during GnRH antagonist administration in IVF/ICSI cycles: a prospective randomized study

BACKGROUND

When administered in the late follicular phase to prevent an LH surge, GnRH antagonists induce a sharp decrease in serum LH levels that may be detrimental for assisted reproductive technology cycle outcome. Therefore, a prospective study was designed to assess the effects of recombinant human (r)LH supplementation during GnRH antagonist (cetrorelix) administration.

METHODS

The protocol consisted of cycle programming with oral contraceptive pill, ovarian stimulation with rFSH and flexible administration of a single dose of cetrorelix (3 mg). A total of 218 patients from three IVF centres were randomized (by sealed envelopes or according to woman's birth date) to receive (n = 114) or not (n = 104) a daily injection of rLH 75 IU from GnRH antagonist initiation to hCG injection.

RESULTS

The only significant difference was a higher serum peak E2 level in patients treated with rLH (1476 +/- 787 versus 1012 +/- 659 pg/ml, P < 0.001) whereas the numbers of oocytes and embryos as well as the delivery rate (25.2 versus 24%) and the implantation rate per embryo (19.1 versus 17.4%) were similar in both groups.

CONCLUSIONS

These results show that in an unselected group of patients, there is no evident benefit to supplement GnRH antagonist-treated cycles with rLH.

Maturation in vitro des ovocytes : bilan et perspectives dans l’espèce humaine

Mature oocytes are rare and highly specialized cells. In vitro maturation of human oocytes is an emerging assisted reproductive technology allowing to produce more mature oocytes without ovarian stimulation. Whereas in vitro maturation is technically more demanding than conventional in vitro fertilization for the laboratory, it carries many potential advantages, for example, in terms of lower treatment heaviness and removal of risk of severe ovarian hyperstimulation syndrome for the patients. Although the technology is still experimental, oocytes in vitro maturation has been successfully used and pregnancies and live births have been reported. Despite these successes, the overall efficiency of in vitro maturation remains low and this procedure must still be improved. The different steps of in vitro maturation process are shown and discussed as well as results in terms of pregnancy and live birth rates.

[Should infertile women with polycystic ovarian syndrome be treated with metformine?]

Polycystic ovary syndrome is a frequent endocrine disorder often associated with insulin resistance and hyperinsulinaemia which may play a role in hyperandrogenism and anovulation. The use of "insulin sensitizing" agents has been suggested to reduce insulin resistance and hyperandrogenism. In that respect, the use of metformin in polycystic ovary syndrome is reviewed. Although its mechanism of action is still unclear, metformin proved to be effective to restore cyclicity and spontaneous ovulation. The synergistic effect of clomiphene citrate and metformin was demonstrated in some studies, suggesting that metformin could be helpful for women with clomiphene citrate resistance. However, the potential effect of metformin administration for reducing hyperstimulation in women treated with exogenous FSH, or for preventing early miscarriages has to be confirmed. Here, we propose a guideline for the use of metformin, as an adjuvant therapy, to restore cyclicity and ovulation in women with polycystic ovary syndrome.

Beneficial effects of GnRH agonist administration prior to ovarian stimulation for patients with a short follicular phase

A short follicular phase is an early clinical feature of declining reproductive competence. The shortening of the follicular phase length is related to both advanced recruitment and selection of the dominant follicle secondary to an earlier and higher FSH rise during the luteal-follicular transition, while the late follicular growth is normal. As a short follicular phase may be detrimental for reproduction, it was postulated that increasing the duration of follicular phase could improve conception rate. For that purpose, gonadotrophin-releasing hormone agonist minidoses were administered in the mid-luteal phase to prevent the intercycle FSH rise before tailoring follicular growth by controlled exogenous FSH administration. This regimen, applied to 69 infertile ovulatory women with a short follicular phase (9.6 +/- 1.2 days) actually lengthened the follicular phase by about 3 days. It proved to be effective in 179 cycles to induce paucifollicular development (1.8 +/- 0.9 follicles) with a low cancellation rate (4%) and a moderate requirement for gonadotrophins [13.3 +/- 6.3 ampoules (75 IU)]. In those women with a high frequency (80%) of elevated basal FSH or oestradiol concentrations, the pregnancy rate reached 15.1%/cycle but the miscarriage rate remained high (44%). Thus, increasing the follicular phase length in patients with a short follicular phase may partially restore fecundity.

[Benefits and risks of ovarian stimulation before intrauterine insemination]

Performance of intra-uterine insemination (IIU) is generally advocated as a first line therapy for infertility related to cercical hostility, male factor, unexplained infertility or mild endometriosis. IIU are usually performed following stimulation of ovulation, even in absence of anovulation. However the rationale for such a systematic ovulation induction is still questionable. Indeed, while an overall assessment of ovarian stimulation tends to conclude to a beneficial effect of these treatments in unexplained or some male infertility, it is clear that no definitive conclusion can be drawn. Indeed, the methodology in many published series is mostly inadequate, data are usually not analysed according to the type of infertility or to the female hormonal features. Finally, adverse effects are imperfectly descripted. A more accurate analysis of these data in relation to the number of recruited follicles definitively shows that, if a bifollicular development is associated with a significant increase in the pregnancy rates, there is no advantage to stimulate further the ovary. Indeed, surpassing the recruitment of two follicles would lead to dramatically increase the risk of OHSS and multiple pregnancies. Thus, further investigations including prospective, randomized studies are needed to better define what should be the most adequate regimen of ovulation induction. Specifically, tailoring the rate of multifollicular development according to the duration, the type of infertility (etiology; primary or secondary; female age) would prove to be a safer approach for getting pregnancy as well as avoiding adverse effects. Such a policy remains to be determined in the light of further clinical studies conducted in the more appropriate manner.

Effectiveness of low dose of gonadotropin releasing hormone agonist on hormonal flare-up

PURPOSE

The hormonal response (flare-up) following administration of a standard dose (100 micrograms) or a low dose (25 micrograms) of gonadotropin releasing hormone agonist (GnRH-a) (Triptorelin) was compared in patients prior to an in vitro fertilization (IVF) cycle and during the early follicular phase of a short-term IVF protocol.

METHODS

The gonadotroph (FSH, LH) and steroid [estradiol (E2) and progesterone (P)] flare-up was studied on two consecutive cycles in 30 normo-ovulatory women. Patients were randomized to receive either 25 or 100 micrograms of triptorelin for three days at the beginning of the first cycle. Then doses were switched according to a crossing over design in the second cycle.

RESULTS

No significant difference in the magnitude of FSH and E2 release could be observed following administration of the two doses of agonist whereas maximal plasma LH level was significantly reduced after injection of 25 micrograms of triptorelin.

CONCLUSIONS

As compared to a standard dose, using a low dose of GnRH-a induces an hormonal flare-up which seems adequate for an optimal follicular recruitment.

[Revisiting GnRH analog protocols II. Strategy for poor responders]

In the first part of this review, we analyzed protocols for ovarian hyperstimulation with GnRH analogs and stressed both their diversity and uncertainty for mechanisms which lead to improve the outcome of IVF cycles. Apart from their beneficial effects on prevention of endogenous LH surges and premature luteinization, other adverse effects have been reported: need of higher amount of exogenous gonadotrophins, direct negative action on ovarian function and conceptus quality. They must be considered before defining a strategy for poor responders to IVF protocols using GnRH analogs. The recent trend for reducing GnRH doses must be evaluated.

Sequential step-up and step-down dose regimen: an alternative method for ovulation induction with follicle-stimulating hormone in polycystic ovarian syndrome

This study was designed to compare both the effectiveness and safety of two low-dose gonadotrophin regimens (step-up versus sequential step-up and step-down) for ovulation induction in polycystic ovarian syndrome (PCOS) patients. In all, 56 infertile clomiphene citrate-resistant PCOS patients were included in this prospective randomized study. A total of 38 cycles were conducted with a classic step-up protocol, whereas for 35 cycles the follicle-stimulating hormone (FSH) threshold dose was reduced by half when the leading follicle reached 14 mm in diameter (sequential protocol). Serum oestradiol, progesterone and luteinizing hormone concentrations and follicular growth rate were evaluated during the cycle. At the time of human chorionic gonadotrophin administration, cycles treated with sequential protocol exhibited significantly lower oestradiol concentrations [434 +/- 45 versus 593 +/- 67 pg/ml (mean +/- SEM)] and the number of medium-sized (14-15 mm) follicles was significantly reduced (0.3 +/- 0.1 versus 0.8 +/- 0.2) compared with cycles treated with the classic step-up protocol. Moreover, in these cycles serum luteal oestradiol concentrations were decreased significantly (350 +/- 77 versus 657 +/- 104 pg/ ml) compared with the classic step-up protocol. A sequential step-up and step-down protocol seems to be a safe and effective regimen for ovulation induction in PCOS patients. Decreasing the FSH dose following step-up follicular selection may be an alternative method to avoid multifollicular development.

The hormonal flare-up following gonadotrophin-releasing hormone agonist administration is influenced by a progestogen pretreatment

In a short-term protocol, the influence of progestogen pretreatment upon the oestradiol flare-up (delta E2) induced by gonadotrophin-releasing hormone agonist (GnRHa) was assessed in relation to in-vitro fertilization (IVF) outcome in 90 cycles programmed (n = 52) or not (n = 38) by norethisterone (10 mg/day for 12-20 days). Patients pretreated by progestogen had a significantly lower delta E2 value than patients without pretreatment (delta E2 = 26 +/- 5 versus 61 +/- 8 pg/ml, P = 0.003). It could be related to a lower gonadotrophic response for luteinizing hormone (LH) (delta LH = 9 +/- 0.8 versus 14.5 +/- 2.2 IU/l, P = 0.01). The IVF outcome (final oestradiol, number of oocytes or embryos) was similar in both groups and delta E2 was well correlated with these final parameters in each group. A significant rise in serum progesterone was observed only in patients without pretreatment (delta P = 1.1 +/- 0.2 versus 0.1 +/- 0.1 ng/ml, P < 0.0001). Thus norethisterone pretreatment decreases the oestradiol flare-up and prevents the early increase of progesterone (by avoiding some rescue of the corpus luteum or some luteinization of small developing follicles) but does not influence the outcome of the IVF cycle. In clinical practice, evaluation of the hormonal flare-up for predicting IVF outcome must take into account any pretreatment prescription.

[Evaluation of ovarian sensitivity to gonadotrophins: role of ovarian reserve tests]

Among several parameters involved in the age-dependent reduction in conception rate, intra-ovarian factors, specially the follicular oocyte complex, play a major role. The aim of endocrine challenge tests is to assess ovarian follicular reserve. Basal serum FSH determination on day 3 of the cycle is easily measurable, inexpensive. Its sensitivity is increased with a clomiphene citrate challenge test. Both GnRH agonist stimulation test and exogenous FSH test allow to evaluate more directly the ovarian function. However they are more invasive, expensive and need further standardisation.

Progestogen pretreatment in the short-term protocol does not affect the prognostic value of the oestradiol flare-up in response to a GnRH agonist

The prognostic value of the oestradiol flare-up in response to gonadotrophin-releasing hormone (GnRH) agonist was evaluated in 140 in-vitro fertilization (IVF) cycles programmed by progestogen pretreatment. Three days after the end of administration of norethisterone, a routinely used short-term DTRP6 GnRH agonist protocol was started (designated day 1), gonadotrophins being introduced from day 4. Serum oestradiol flare-up values were evaluated on days 1, 2 and 3 to study their relationship with the subsequent IVF outcome. On day 2, 87.9% of the cycles exhibited a significant rise in serum oestradiol concentration from baseline (delta E2 > or = 5 pg/ml). Compared to cycles without any significant oestradiol increase, they had a higher pregnancy rate per transfer (33.3 versus 9.1%, P = 0.02), although the number of transferred embryos did not differ significantly. Taking into account the previously described cut-off value (doubling from baseline), we found that less than half of the cycles (45.7%) involved a doubling of oestradiol values during flare-up, and we did not observe any significant difference in IVF outcome in these cycles compared to those without doubling. In conclusion, progestogen pretreatment, by inducing ovarian quiescence, may lower the oestradiol cut-off value that is predictive of the subsequent pregnancy rate. Nevertheless, determination of the absolute oestradiol response (delta E2) to GnRH agonist after progestogen pretreatment could allow a further adaptation of the protocol to achieve an optimum response in each cycle. Another alternative for patients with a lower delta E2 could be the suppression of progestogen pretreatment.