Abstract
Abstract: Objective: To determine the efficacy of clomiphene citrate (CC) in preventing luteinizing hormone (LH) surge without adding gonadotropin releasing hormone (GnRH) antagonist or GnRH agonist in stimulated first fresh intracytoplasmic sperm injection cycle by evaluating the outcome of oocytes and embryo quality. Design: Registry cohort study. Settings: Fertility Clinic Registry at Hospital University Kebangsaan Malaysia. Patients: A total of 235 fresh stimulated ICSI cycle for patients aged 18-40 years old using clomiphene citrate plus gonadotropin (n = 117) and GnRH antagonist plus gonadotropin (n = 118) were studied. Intervention: Comparing two different ovarian stimulation protocol. Main outcome measure(s): Social economical demographic, ovarian stimulation response and laboratory outcome. Fertilization rate as our primary outcome and our secondary outcome were oocyte retrieval rate, mature oocyte rate and top quality embryo rate. Result(s):There were no difference in the demographic and hormonal characteristic of the study groups. The primary outcome of fertilization rate has significant difference with p value of 0.003; 73.2% for CC group and 64.2% for GnRH antagonist group. The secondary outcome of OR rate (78.4% ± 17.6% VS 80.3% ± 13.4%, p = 0.368), mature oocyte rate (85.2% ± 19.0 VS 81.7% ± 16.7%, p = 0.130) and top quality embryo rate (79.4% ± 24.2% VS 74.9% ± 22.9%, p = 0.178) were comparable between both groups. There were significant difference between the endometrial thickness on the day of trigger and OHSS risk among both groups (8.5 mm ± 1.0 mm VS 9.4 mm ± 1.1 mm, p < 0.001 and 12.8% VS 44.1% respectively). Discussion: Minimal stimulation protocol with CC and gonadotropin may be the answer to many infertile couples in need of IVF and yet having financial situation deterring them in attempting IVF treatment. GnRH antagonist could be safely replaced by CC by extending to 10 days as this protocol gives better primary outcome and comparable secondary outcomes with less OHSS. CC is recognized to induce thinning of endometrial lining and thus, may impair embryo implantation. However, with advancement of the vitrification system and higher success rate in frozen-thaw embryo transfer worldwide provides an excellent solution for this issue.
Highlights
Controlled ovarian stimulation (COS) is an important component in IVF in order to yield optimum number of oocytes with the aim of achieving the best pregnancy outcome [1]
Minimal stimulation protocol with clomiphene citrate (CC) and gonadotropin may be the answer to many infertile couples in need of IVF and yet having financial situation deterring them in attempting IVF treatment
Premature luteinizing hormone (LH) surge during ovarian stimulation has become the main concern for clinicians [6] as it would lead to poor quality of oocyte, poor fertilization and cycle cancellation
Summary
Controlled ovarian stimulation (COS) is an important component in IVF in order to yield optimum number of oocytes with the aim of achieving the best pregnancy outcome [1]. There are various protocol that were created to assist patient to conceive without compromising the outcome, such as cycle cancellation due to premature ovulation secondary to LH surge and unwanted complication such as ovarian hyperstimulation syndrome (OHSS). Shiuan Yee Tan, Salleha Khalid, Mohamad Azrai Abu, Abdul Kadir Abdul Karim, Mohd Hashim Omar tion and stimulation days for patients undergoing ICSI [1, 2, 3]. It has become a popular for patients with good prognosis, poor responders and women of advanced age as an alternative to conventional protocol [1, 4, 5]. This explained the reason of using GnRH antagonist protocol as a control in our study
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