Ideal frozen embryo transfer regime

PURPOSE OF REVIEW

This review aims to compare evidence on four criteria (embryo implantation, obstetric outcomes, patient convenience, and IVF-unit efficiency) by analyzing published research on different endometrial preparation methods for frozen embryo transfer (FET).

RECENT FINDINGS

While the artificial-FET cycle provides advantages in scheduling and implantation, it falls short in ensuring optimal obstetric outcomes. In contrast, natural-FET ensures embryo implantation conditions if ovulation is correctly identified. Supplementing with exogenous progesterone shields against low corpus luteum progesterone secretion, crucial for positive obstetric outcomes. In mNC-FET, ovulation is hCG-triggered, closely resembling natural cycles and reducing monitoring visits for enhanced patient convenience.Letrozole is a recommended option for anovulatory patients, preserving endometrial thickness. It is cost-effective, less likely to induce multifollicular development than gonadotropins, and better tolerated.In a novel approach, the natural-proliferative-phase-FET initiates progesterone in an unmediated ovulatory cycle at 7 mm endometrial thickness, combining the benefits of a natural proliferative endometrium with the convenience of scheduled artificial cycles.

SUMMARY

The artificial cycle offers scheduling advantages, but may compromise obstetric outcomes. Natural FET relies on accurate ovulation timing for successful implantation. mNC-FET simplifies the process using hCG induction, minimizing clinic visits for improved convenience. Letrozole is highlighted as a cost-effective and well tolerated option in anovulatory patients. A recent innovative approach combines elements of natural and artificial cycles, showing promise for FET procedures.

LH supplementation in IVF: human nature, politics, and elephants in the room

Luteinizing hormone (LH) is present throughout the natural follicular phase. However, the debate is still not settled on whether LH is needed during ovarian stimulation in IVF. This commentary looks at the evolution of this debate, mentioning three elephants in the room that were ignored by the Pharma industry, professional organizations, and clinicians alike: 1. The different endocrinology between the long agonist and the antagonist protocols. 2. The fixed dose of the two most widely commercially available antagonist preparations, namely cetrorelix and ganirelix. 3. The fact that most research in this area uses population-based criteria, ignoring endocrine parameters. Individual genetics of the LH receptor gene may also serve to individualize LH needs during stimulation; however, the jury is still out regarding this approach. CONCLUSIONS: Individual endocrine and genetics parameters may shed meaningful light on the question of LH supplemental during ovarian stimulation.

[IN VITRO FERTILIZATION (IVF) TREATMENTS IN MACCABI HEALTHCARE SERVICES 2015-2020]

BACKGROUND

Previously, we have summarized IVF treatment outcomes for the years 2007-2014. In 2014, the Ministry of Health (MOH) recommended that infertile patients above 39 years of age can be offered IVF as a first line treatment, given the natural age-related decrease in ovarian reserve.

OBJECTIVES

The purpose of the current publication is to summarize IVF treatment outcomes for the years 2015-2020, and to explore possible changes in IVF treatments following the MOH statement.

METHODS

IVF treatments and live birth data were collected from Maccabi Healthcare Services' fertility treatments registry. We have included only autologous fresh and frozen embryo transfer (FET) cycles. A successful treatment cycle was defined if a live birth was recorded between 6 to 10 months of its initiation.

RESULTS

Mean patients' age increased from 36.2 years in 2011 to 37.5 years in the 6 years surveyed (2015-2020). While the number of fresh cycles was stable, the number of FET cycles increased from 4,507 in 2015 to 6,795 in 2020. The percentage of cycles performed in private hospitals increased gradually from 72% in 2015 to 77% in 2020. The number of patients over 40 years of age increased from 3,204 in 2011, to 3,648 in 2014, and to 3,915 in 2020.

CONCLUSIONS

The total number of IVF cycles increased gradually from 2015 to 2020, mainly due to significant increase in FET cycles. The continued increase in mean patients' age may reflect the change in MOH recommendations.

Time-sensitive assessment of luteal phase progesterone after HCG ovulation triggering: another brick off the wall?

In recent years, there has been growing interest in understanding the dynamics of progesterone levels during the luteal phase after HCG-triggered ovulation. Recent studies have provided data showing a deviation from the natural ovulatory cycle, with peak progesterone concentrations occurring earlier and declining steadily thereafter, demonstrating that a fall in progesterone concentration early in the luteal phase was associated with lower rates of ongoing pregnancy. These findings highlight the importance of changes in progesterone concentration, rather than absolute concentrations, in determining optimal endometrial conditions. The disadvantages of HCG triggering, including the lack of a natural FSH surge and asynchronization between embryo age and endometrium receptivity, can be addressed by using gonadotrophin-releasing hormone agonist (GnRHa) triggering. GnRHa triggering induces both LH and FSH surges, ensures appropriate progesterone concentrations and offers flexibility in manipulating the luteal phase. Transitioning to GnRHa triggering could improve infertility treatment.

Time, time, time: see what governs the luteal phase endocrinology

Two modes of ovulation trigger are used in IVF: hCG, acting on ovarian LH receptors, and GnRH agonist, eliciting pituitary LH and FSH surges. These two modes are evaluated herein, focusing on how they serve specific time-sensitive events crucial for achieving embryo implantation and pregnancy. hCG trigger is associated with significant timing deviation from physiology. Peak progesterone is not synchronized with implantation window; progesterone level does not rise continuously to a mid-luteal peak, but rather drops from a too early peak. The luteal phase endocrinology post GnRH agonist trigger is characterized by a quick and irreversible luteolysis. Therefore, freeze all strategy is advised, if there is a risk of ovarian hyperstimulation syndrome. If fresh transfer is desired, numerous approaches for luteal phase support have been suggested. However, a thorough understanding of time-sensitive events suggests that a single 1,500 IU hCG dose, administered 48 h post oocyte retrieval, is all that is needed to fully support the luteal phase and secure best chances of achieving pregnancy.

IVF and the exogenous progesterone-free luteal phase

PURPOSE OF REVIEW

In a conventional IVF cycle, final oocyte maturation and ovulation is triggered with a bolus of hCG, followed by progesterone-based luteal support that spans several weeks if pregnancy is achieved. This article summarizes several approaches of the exogenous progesterone-free luteal support in IVF.

RECENT FINDINGS

Triggering ovulation with GnRH agonist may serve as an alternative to hCG, with well established advantages. In addition, the luteal phase can be individualized in order to achieve a more physiologic hormonal milieu, and a more patient friendly treatment, alleviating the burden of a lengthy exogenous progesterone therapy.

SUMMARY

GnRH agonist trigger followed by a 'freeze all' policy is undoubtedly the best approach towards the 'OHSS-free clinic'. If fresh embryo transfer is considered well tolerated after GnRH agonist trigger, rescue of the corpora lutea by LH activity supplementation is mandatory. Herein we discuss the different approaches of corpus luteum rescue.

Reduced FSH and LH action: implications for medically assisted reproduction

Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) play complementary roles in follicle development and ovulation via a complex interaction in the hypothalamus, anterior pituitary gland, reproductive organs, and oocytes. Impairment of the production or action of gonadotropins causes relative or absolute LH and FSH deficiency that compromises gametogenesis and gonadal steroid production, thereby reducing fertility. In women, LH and FSH deficiency is a spectrum of conditions with different functional or organic causes that are characterized by low or normal gonadotropin levels and low oestradiol levels. While the causes and effects of reduced LH and FSH production are very well known, the notion of reduced action has received less attention by researchers. Recent evidence shows that molecular characteristics, signalling as well as ageing, and some polymorphisms negatively affect gonadotropin action. These findings have important clinical implications, in particular for medically assisted reproduction in which diminished action determined by the afore-mentioned factors, combined with reduced endogenous gonadotropin production caused by GnRH analogue protocols, may lead to resistance to gonadotropins and, thus, to an unexpected hypo-response to ovarian stimulation. Indeed, the importance of LH and FSH action has been highlighted by the International Committee for Monitoring Assisted Reproduction Technologies (ICMART) in their definition of hypogonadotropic hypogonadism as gonadal failure associated with reduced gametogenesis and gonadal steroid production due to reduced gonadotropin production or action. The aim of this review is to provide an overview of determinants of reduced FSH and LH action that are associated with a reduced response to ovarian stimulation.

The exogenous progesterone-free luteal phase: two pilot randomized controlled trials in IVF patients

RESEARCH QUESTION

Is the reproductive outcome similar after gonadotrophin-releasing hormone agonist (GnRHa) trigger followed by luteal human chorionic gonadotrophin (HCG) boluses compared with HCG trigger and a standard luteal phase support (LPS)?

DESIGN

Two open-label pilot randomized controlled trials (RCT) with 250 patients from 2014 to 2019, with a primary outcome of ongoing pregnancy per embryo transfer. Patients with ≤13 follicles on the trigger day were randomized (RCT 1) to: Group A (n = 65): GnRHa trigger followed by a bolus of 1500 IU HCG s.c. on the oocyte retrieval day (ORD) and 1000 IU HCG s.c. 4 days later, and no vaginal LPS; or Group B (n = 65): 6500 IU HCG trigger, followed by a standard vaginal progesterone LPS. Patients with 14-25 follicles on the trigger day were randomized (RCT 2) to Group C (n = 60): GnRHa trigger followed by 1000 IU HCG s.c. on ORD and 500 IU HCG s.c. 4 days later, and no vaginal LPS; or Group D (n = 60): 6500 IU HCG trigger and a standard vaginal LPS.

RESULTS

In RCT 1, the ongoing pregnancy rate was 44% (22/50) in the GnRHa group versus 46% (25/54) in the HCG trigger group (RR 0.95, 95% CI 0.62-1.45). No ovarian hyperstimulation syndrome (OHSS) was seen in Groups A or B. In RCT 2, the ongoing pregnancy rate was 51% (25/49) in the GnRHa group versus 60% (31/52) in the HCG trigger group (RR 0.86, 95% CI 0.60-1.22). The OHSS rates were 3.3% and 6.7%, respectively.

CONCLUSIONS

Although a larger-scale study is needed before standard clinical implementation, the present study supports that the exogenous progesterone-free LPS is efficacious, simple and patient-friendly.

GnRH agonist triggering followed by 1500 IU of HCG 48 h after oocyte retrieval for luteal phase support

RESEARCH QUESTION

Gonadotrophin releasing hormone (GnRH) agonist trigger after GnRH antagonist-based ovarian stimulation protocol for IVF is gaining popularity, because it prevents ovarian hyperstimulation syndrome and allows for near physiological LH and FSH surges. A small dose of HCG (1500 IU) on the day of oocyte retrieval, followed by daily progesterone administration, is currently the preferred way to secure adequate luteal support after GnRH agonist trigger. In the present study, the possibility that a bolus of 1500 IU HCG, given 2 days after oocyte retrieval, may be sufficient to sustain adequate luteal support without additional progesterone treatment was questioned.

DESIGN

A non-interventional retrospective cohort study between conducted between April 2017 and August 2018. A total of 154 consecutive patients treated with GnRH agonist trigger followed by day-2 HCG (1500 IU) support only (study group) were included. Data were compared with 155 consecutive patients who were treated with HCG (6500 IU) trigger followed by conventional progesterone luteal support (control group).

RESULTS

Pregnancy, miscarriage and live birth rates were comparable between the study and control groups. In patients who became pregnant, mean oestradiol level 14 days after oocyte retrieval was 4719 pmol/l and 2672 pmol/l in the study and control group, respectively (P < 0.001), reflecting robust luteal activity in the study group.

CONCLUSIONS

A bolus of 1500 IU HCG, administered 2 days after retrieval, can provide excellent luteal support, without the need for further progesterone supplementation.

LH Supplementation in Ovarian Stimulation for IVF: The Individual, LH Deficient, Patient Perspective

The availability of recombinant follicle-stimulating hormone (FSH) and luteinizing hormone (LH) opens an opportunity to individualize ovarian stimulation. While the need for FSH in ovarian stimulation is universal, a question remains whether exogenous LH is beneficial. Previous population-based research showed that added LH is indicated in elderly and in profoundly LH depressed patients. This commentary explores potential individual patient parameters that may hint that this specific individual may prospectively need supplemented LH, irrespective of her age or experience from previous cycles. Specifically, it is suggested that in an antagonist protocol, the degree of LH recovery 24 h post first GnRH antagonist injection can identify those patients who may benefit from added LH. In addition, rising LH during the first 5 days of stimulation may predispose patients to a sharp LH drop following the first GnRH antagonist dose, and the need for added LH.

The Importance of Mid-Follicular Phase Luteinizing Hormone Rise in GnRH Antagonist-Based Ovarian Stimulation for IVF

INTRODUCTION

Previous publications examined the endocrinology of follicular stimulation, focusing on luteinizing hormone (LH) levels changes. In selected, good prognosis IVF patients, a sharp drop in LH serum level was demonstrated between cycle days 2 and 6.

OBJECTIVE

The purpose of this study was to examine if this finding holds true for unselected patients.

METHODS

We retrospectively included 165 consecutive patients treated with a GnRH antagonist-based ovarian stimulation protocol during the year 2015.

RESULTS AND CONCLUSIONS

In 33% of the patients an increase in LH, rather than the expected decrease, was demonstrated after 5 stimulation days. There was no difference in pregnancy outcome. Our results suggest that an increase in LH levels during ovarian stimulation occurs mainly in "high responders", or "low responders". LH rise in mid follicular phase may result in a sharp LH drop once a GnRH antagonist is given, and the possible need for LH supplementation.

Distinct and independent dielectrophoretic behavior of the head and tail of sperm and its potential for the safe sorting and isolation of rare spermatozoa

Often, in semen samples with minute amounts of sperm, even the single spermatozoon required to fertilize an oocyte cannot be found in the ejaculate. This is primarily because currently, sperm is generally searched for manually under a microscope. In this study, dielectrophoresis (DEP) was investigated as an alternative automated technique for sorting sperm cells. Using a quadrupolar electrode array it was shown that the head and tail of the sperm had independent and unique crossover frequencies corresponding to the transition of the DEP force from repulsive (negative) to attractive (positive). These surprising results were further analyzed, showing that the head and tail have their own distinct electrical properties. This significant result allows for the sperm's head, which contains the DNA, to be distanced from potentially damaging high electric fields using negative DEP while simultaneously manipulating and sorting the sperm using the positive DEP response of the tail. A proof of concept sorting chip was designed and tested. The low crossover frequency of the tail also allows for the use of a higher conductivity, and thus more physiological, medium than the conventional DEP solutions. Although more research is required to design and optimize an efficient, user-friendly, and high-throughput device, this research is a proof of concept that DEP has the potential to automate and improve the processing of semen samples, especially those containing only rare spermatozoa.

Ultra-Orthodox Jews and infertility diagnosis and treatment

BACKGROUND

'Be fruitful and multiply' is the first God's command in the Bible. Every aspect in life of the Orthodox Jewish population, including the strive for fertility, is tightly covered by a wide set of commands and rules ('Halacha') that span more than 3,000 years. This is a unique example of a population that continues to adhere to such time-honored rules.

OBJECTIVE

To describe rules that encourage fertility on one hand, but may hinder fertility and influence infertility diagnosis and treatment on the other.

MATERIALS AND METHODS

Halacha rules that may affect fecundity.

RESULTS

Orthodox Jews obey a complex set of rules that influence fertility.

DISCUSSION AND CONCLUSION

This study provides fertility practitioners with background information that may help them when delivering professional care to Ultra-Orthodox Jewish infertile couples.

A Rationale for Timing of Luteal Support Post Gonadotropin-Releasing Hormone Agonist Trigger

Gonadotropin-releasing hormone (GnRH) antagonist-based ovarian stimulation protocol is gaining popularity. This protocol allows for the use of GnRH agonist as a trigger of final oocyte maturation, instead of the "gold standard" human chorionic gonadotropin (hCG) trigger. GnRH agonist trigger causes quick luteolysis, hence its widespread use in the context of ovarian hyperstimulation syndrome (OHSS) prevention. To secure pregnancy post GnRH agonist trigger, the luteal phase must be supplemented to counteract the luteolysis. Several luteal phase protocols post GnRH agonist trigger have been suggested, most notably based on increasing luteal luteinizing hormone (LH) activity (by adding LH or hCG). The current review aims at delineating a rationale for timing luteal support with a single hCG bolus post GnRH agonist trigger. The review also suggests a set of simple rules that must be followed when designing luteal phase support post GnRH agonist trigger.

Computer Implementation of the New Diabetes Classification Scheme

The classification of diabetes and other categories of glucose intolerance developed by the international workgroup sponsored by the National Diabetes Data Group of the NIH has been implemented on the computer, using a system for the simulation of medical reasoning. The system allows the physician to formulate his medical knowledge as a series of logical inferences and to specify those combinations of clinical findings which confirm or reject each inference. Alphabetical lists of the texts of medical statements appearing in the knowledge base are used to specify patient data. A patient status report is produced by comparing the patient data with the medical logic. The report lists patient data, the inferences confirmed and, if necessary, requests additional data to complete the classification. The system has enabled us to computerize the new classification scheme in a relatively short time and with a minimum of effort. The system has correctly classified nearly 100 patients on our ward and in the endocrinology clinics using data routinely recorded. The computer evaluation is now an integral part of the patient record. It assures that the new classification scheme is applied to all patients in an unbiased and consistent manner.

Day two post retrieval 1500 IUI hCG bolus, progesterone-free luteal support post GnRH agonist trigger - a proof of concept study

Small dose of hCG (1500 IU) on the day of oocyte retrieval, followed by daily progesterone administration, is currently the preferred way to secure adequate luteal support following GnRH agonist trigger. In the current proof-of-concept study, we explored the possibility that a bolus of 1500 IU hCG, given two days after oocyte retrieval, may be sufficient to sustain adequate luteal support without additional progesterone treatment. From February 2015 to August 2016, we obtained 44 pregnancies following GnRHa trigger followed by day 2 hCG (1500 IU) support only (study group). Data from these 44 cycles were compared with the latest 44 pregnancies obtained following hCG (6500 IU) trigger followed by conventional progesterone luteal documented (control group). Mean progesterone levels (14 days postoocyte retrieval) in the study and control groups were 197 nmol/l and 173 nmol/l, respectively (NS). Mean E₂ levels (14 days post oocyte retrieval) in the study group was 6937 pmol/l, significantly higher (p < .001) than in the control group (3.276 pmol/l). We conclude that bolus of 1500 IU hCG, administered 2 days after retrieval, can provide excellent support, without the need to further supplement with progesterone.

GnRH-agonist triggering for final oocyte maturation in GnRH-antagonist IVF cycles induces decreased LH pulse rate and amplitude in early luteal phase: a possible luteolysis mechanism

The use of GnRH agonist to trigger final oocyte maturation in GnRH-antagonist in vitro fertilization (IVF) cycles has been shown to significantly reduce or even eliminate the risk of ovarian hyperstimulation syndrome (OHSS) by inducing rapid luteolysis early in the luteal phase. The exact mechanism of this early luteolysis is still widely unknown. Since luteinizing hormone (LH) has a major role in corpus luteum support, we sought to explore the pattern of LH secretion early in the luteal phase. Ten high risk patients for developing OHSS and triggered with GnRH agonist were included. Frequent blood sampling (every 20 min for 6 h) to measure LH, estradiol and progesterone was done on the day of oocyte collection (n = 5, Group 1) and on the day of embryo transfer, 48 h after oocyte collection (n = 5, Group 2). We found that the mean LH concentration and its secretion rate decreased significantly in Group 2 compared to Group 1. Both groups had similar number of LH pulses characterized by very small amplitude. In Group 2, there was a steady significant decrease in estradiol and progesterone over time. The results of this study show that LH secretion deviates significantly from normal physiologic pattern, which can explain, at least in part, the post-GnRH-agonist trigger early luteolysis mechanism.

GnRH Agonist Triggering of Ovulation Replacing hCG: A 30-Year-Old Revolution in IVF Practice Led by Rambam Health Care Campus

Final oocyte maturation is a crucial step in in vitro fertilization, traditionally achieved with a single bolus of human chorionic gonadotropin (hCG) given 36 hours before oocyte retrieval. This bolus exposes the patient to the risks of ovarian hyperstimulation syndrome (OHSS), particularly in the face of ovarian hyper-response to gonadotropins. Although multiple measures were developed to prevent OHSS, gonadotropin-releasing hormone (GnRH) agonist triggering is now globally recognized as the best approach to achieve this goal. The first report on the use of GnRH agonist as ovulation trigger in the context of OHSS prevention came from Rambam Health Care Campus, Haifa, Israel and appeared in 1988. This review details the events that culminated in worldwide acceptance of this measure and describes its benefit in the field of assisted reproductive technology.

Anovulatory Patients Demonstrate a Sharp Decline in LH Levels upon GnRH Antagonist Administration during IVF Cycles

To evaluate the decrease in luteinizing hormone (LH) levels following gonadotropin-releasing hormone (GnRH) antagonist administration in in vitro fertilization (IVF) cycles, data were retrospectively collected from 305 consecutive IVF or intracytoplasmic sperm injection (ICSI) cycles of patients who underwent ovarian stimulation with gonadotropins and were treated with GnRH antagonist for the prevention of premature luteinization. We compared the percent change in LH concentration from stimulation start to that observed before ovulation triggering in patients with or without anovulation. Anovulatory patients were younger, with higher body mass index (BMI), and demonstrated higher ovarian reserve parameters as compared to ovulatory patients. The decline in LH concentration was almost two-fold greater in anovulatory versus ovulatory patients. Numbers of oocytes, fertilizations, cleavage stage embryos, and transferred embryos were similar; however, implantation rates were higher in anovulatory versus ovulatory patients. Older patients (age ≥39) showed a smaller decline in LH levels as compared to younger ones (age <39) and exhibited poor IVF outcomes. There is a wide range of pituitary responses to GnRH antagonists. Anovulatory patients are more susceptible to GnRH antagonists and therefore demonstrate over-suppression of the pituitary. Older patients demonstrate a reduced pituitary response to GnRH antagonists than younger ones. Cycle scheduling with estradiol pretreatment did not influence LH decline, nor IVF treatment outcomes.

In Vitro fertilization (IVF) treatments in Maccabi Healthcare Services 2007-2014

BACKGROUND

Israel reports the world's highest IVF cycles per capita. However, clinical outcome data of these treatments are scarce. In a previous publication, we summarized IVF results among Maccabi Healthcare Services members for the years 2007-2010. The main findings included an increase in mean patients' age over the period studied, a 50 % increase in cycle numbers during this time, and a decrease in success rate (live birth) from 18.8 % in 2007 to 14.8 % in 2010. The purpose of the current publication is to summarize IVF outcome for the years 2011-2014, and to explore possible changes in the trends we reported previously.

METHODS

IVF and live births data were collected from Maccabi Healthcare Services' fertility treatments registry. Analyses were conducted by treatment year and patients' age at the initiation of treatment cycles. Autologous cycles, were included (ovum donation cycles and frozen-thaw cycles were excluded). A successful cycle was defined if a live birth was recorded within 10 months of its initiation.

RESULTS

In accordance with previous data for the years 2007-2010, mean patients' age continued to rise (from 36.2 in 2011 to 37.1 in 2014). In contrast to previous years, during which a continued increase in treatment cycles was recorded, we found that treatment number decreased from a peak of 9,751 in 2011 to 8,623 in 2014. Contrary to that trend, the number of patients over 40 years of age increased from 3,204 in 2011 to 3,648 in 2014. Success rate fluctuated between 14.4 % in 2014 to 16.4 % in 2013. The majority (78 %) of treatment cycles were conducted in four private medical centers.

CONCLUSIONS

The decrease in treatment cycles in recent years notwithstanding, Israel is still leading the world with IVF treatments relative to population. Success rate is relatively low compared to international data. Given the steady increase in patients' mean age, and particularly, the increase in patients over 40 years of age, we maintain that the low success rate reflects a growing number of treatments that a priori have a low chance of success.

Treatment Strategies for the Infertile Polycystic Ovary Syndrome Patient

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age. Infertility is a prevalent presenting feature of PCOS, and approximately 75% of these women suffer infertility due to anovulation. Lifestyle modification is considered the first-line treatment and is associated with improved endocrine profile. Clomiphene citrate (CC) should be considered as the first line pharmacologic therapy for ovulation induction. In women who are CC resistant, second-line treatment should be considered, as adding metformin, laparoscopic ovarian drilling or treatment with gonadotropins. In CC treatment failure, Letrozole could be an alternative or treatment with gonadotropins. IVF is considered the third-line treatment; the ‘short’, antagonist-based protocol is the preferred option for PCOS patients, as it is associated with lower risk of developing ovarian hyperstimulation syndrome (specifically by using a gonadotropin-releasing hormone agonist as ovulation trigger), but with comparable outcomes as the long protocol.

Luteal phase support post IVF: individualized early stop

While the need for progesterone-based luteal phase support is well documented, the required treatment duration is not well established, and a practitioners' survey showed a wide range of empiric stopping points. It is suggested that an early stop can be based on assessing endogenous luteal activity on the day of pregnancy test. To examine this approach, data were retrospectively collected on 99 patients with positive pregnancy test and high serum concentrations of oestradiol and progesterone (≥ 1000 pmol/l and ≥ 110 nmol/l, respectively), whose luteal support was stopped, and compared with those of 85 patients who did not meet the above criteria, and so luteal support was continued until gestational week 9. Both groups were comparable in terms of live birth and miscarriage rates. We conclude that in the face of strong endogenous luteal activity, exogenous support can be stopped on pregnancy test day, without affecting pregnancy outcome. Further research is needed to substantiate this finding.

Individualized Treatment from Theory to Practice: The Private Case of Adding LH during GnRH Antagonist-based Stimulation Protocol

The study evaluated the proportion of patients whose pituitary glands respond with a sharp decrease in luteinizing hormone (LH) levels when exposed to a conventional dose of 0.25 mg gonadotropin releasing hormone (GnRH) antagonist in a prospective, single-center, non-randomized, proof-of-concept study. Fifty women eligible for in vitro fertilization (IVF) received recFSH (Gonal-F) from day 2 or 3 of menstrual period. Basal estradiol, progesterone, and LH were measured on the same day and 4–5 days later—immediately before GnRH antagonist 0.25 mg administration, and 24 hours after its administration. Responders were defined as “normal” if 24 hours after the first GnRH antagonist injection, LH level was ≥50% of the pre-injection level and as “over-suppressed” if it was <50% of the pre-injection level. Twelve patients (26% of the total) were “over-suppressed” with a mean LH level of 37% of the level 24 hours earlier. These patients also demonstrated a significant decrease in estradiol rise during the first 24 hours after initial antagonist administration. This effect was reversed for the rest of the stimulation period during which recLH (Luveris, 150 IU/day) was added to the “over-suppressed.” If proven advantageous in terms of pregnancy rate, this approach to individualized treatment would be easy to implement. Trial registration: ClinicalTrials. gov Identifier: NCT01936077.

The use of portable CO2 incubator for cross-border shipping of embryos in an international egg donation program

Two groups of egg recipients were treated, one in situ (165 patients; 195 cycles) and one after cross-border embryo transportation (340 cycles; 340 cycles) using mobile CO(2) incubator. The positive pregnancy rate per cycle was 199/340 (58.6%) and 99/195 (50.7%) in the transportation and the traveling group, respectively (NS). The clinical pregnancy rate (fetal heart beat) was 48.1 and 43.1% per embryo transfer cycle, respectively (NS) and the delivery rate was 44.1 and 35.9% per embryo transfer cycle, respectively (p = 0.01). Long distance transportation of human pre-implantation embryos using portable CO(2) incubator is safe and do not jeopardize their developmental potential.

[Assisted reproductive technology in the presence of chronic viral disease]

INTRODUCTION

The first fertility unit dedicated to the treatment of couples infected with chronic viral diseases in Israel was established at the Rambam Medical Center in 2010. A multidisciplinary approach is needed in order to provide appropriate treatment to the viral disease, and to minimize the risks of infecting the partner, the embryo and others in the fertility unit.

OBJECTIVE

To review 2 years-experience providing fertility care to couples seropositive for HIV, HBV and HCV.

METHODS

Retrospective study.

RESULTS

Between the years 2010-2012, 92 couples underwent 183 oocyte retrievals and fresh embryo transfers and 77 cycles of frozen-thawed embryo transfer. Forty three percent of the couples were seropositive to HBV, 30% seropositive to HIV, 20% seropositive to HCV and 7% infected with more than one virus. In 52.3% of cases the male partner was infected, in 38% the female partner was infected and in 9.7% both partners were infected. Fifty one percent of the couples received antiviral therapy before admission to the unit or did not need antiviral therapy due to inactive disease. Twenty nine percent of the couples received anti-viral drugs while being treated in the fertility unit and 10% needed anti-viral treatment before beginning fertility treatment due to high viral load. Horizontal or vertical viral disease transmissions were not recorded.

CONCLUSION

Upon admission to the fertility unit the majority of couples had good control of their viral infections and either was under anti-viral treatment or did not need any further treatment. From our experience and a review of the literature, controlling the viral disease is the key to safe fertility treatment, and eliminating the risk of infecting the embryo, newborn, partner, and others within the fertility unit.

[In-vitro fertilization cycles and outcomes in Maccabi Healthcare Services in Israel 2007-2010]

INTRODUCTION

While Israel is by far number one in the world of in-vitro fertilization (IVF) treatments per capita, detailed information about the outcome of these treatments is not available.

OBJECTIVES

To describe IVF activity during the years 2007-2010 in Maccabi Healthcare Services, an independent health provider that reimburses IVF treatments.

METHODS

Data on IVF cycles and live births were collected from the Maccabi Healthcare Services infertility registry and analyzed by year and age at cycle start.

RESULTS

During the four years surveyed, the average patients' age rose from 35.12 to 36.19 years. The number of IVF treatments increased by 50%, while the "live birth" rate fell from 18.8% in 2007, to 14.8% in 2010. A drop in success rate was noted in patients >35 years of age, and more so in patients >40 years of age. Beyond 43 years of age, the success rate was in the low one digit range. The estimated cost of a single live birth in this age group is NIS 399,000.

SUMMARY

The clinical results are not encouraging relative to IVF outcomes in Europe and the U.S.A. SurprisingLy, and contrary to worldwide trends, the success rate in Israel decreased during the surveyed years. We speculate that the main reason is that many IVF treatments are conducted in patients that a priori have a very low chance of success. A nationwide prospective IVF registry should be implemented.

GnRH agonist triggering: recent developments

The concept that a bolus of gonadotrophin-releasing hormone agonist (GnRHa) can replace human chorionic gonadotrophin(HCG) as a trigger of final oocyte maturation was introduced several years ago. Recent developments in the area strengthen this premise. GnRHa trigger offers important advantages, including virtually complete prevention of ovarian hyperstimulation syndrome(OHSS), the introduction of a surge of FSH in addition to the LH surge and finally the possibility to individualize luteal-phase supplementation based on ovarian response to stimulation. We maintain that the automatic HCG triggering concept should be challenged and that the GnRHa trigger is the way to move forward with thoughtful consideration of the needs, safety and comfort of our patients.

GnRH agonist for triggering of final oocyte maturation: time for a change of practice?

BACKGROUND

GnRH agonist (GnRHa) triggering has been shown to significantly reduce the occurrence of ovarian hyperstimulation syndrome (OHSS) compared with hCG triggering; however, initially a poor reproductive outcome was reported after GnRHa triggering, due to an apparently uncorrectable luteal phase deficiency. Therefore, the challenge has been to rescue the luteal phase. Studies now report a luteal phase rescue, with a reproductive outcome comparable to that seen after hCG triggering.

METHODS

This narrative review is based on expert presentations and subsequent group discussions supplemented with publications from literature searches and the authors' knowledge. Moreover, randomized controlled trials (RCTs) were identified and analysed either in fresh IVF cycles with embryo transfer (ET), oocyte donation cycles or cycles without ET; risk differences were calculated regarding pregnancy rate and OHSS rate.

RESULTS

In fresh IVF cycles with ET (9 RCTs) no OHSS was reported after GnRHa triggering [0% incidence in the GnRHa group: risk difference 5% (with 95% CI: -0.07 to 0.02)]. Importantly, the delivery rate improved significantly after modified luteal support [6% risk difference in favour of the HCG group (95% CI: -0.14 to 0.2)] when compared with initial studies with conventional luteal support [18% risk difference (95% CI: -0.36 to 0.01)]. In oocyte donation cycles (4 RCTs) the OHSS incidence is 0% [10% risk difference (95% CI: 0.02-0.40)].

CONCLUSIONS

GnRHa triggering is a valid alternative to hCG triggering, resulting in an elimination of OHSS. After modified luteal support there is now a non-significant difference of 6% in delivery rate in favour of hCG triggering.

Change, change, change: hormonal actions depend on changes in blood levels

The main hypothesis outlined in this communication is that changes in hormonal levels are of utmost importance in the female reproductive system physiology. Hormone measurements must be assessed in the context of time and change. We hypothesize that changes in hormone concentrations carry significant biological messages, much more than a given level at a given time point and if proved, this theory could give rise to better approaches to treatment, and risk assessment.