Agonist Protocol Research Articles

Premature progesterone rise on day of hCG negatively correlated with live birth rate in IVF cycles: An analysis of 1022 cycles

ObjectiveTo investigate the relationship between serum P levels on the day of hCG administration and pregnancy outcomes in patients undergoing IVF. DesignRetrospective study. SettingTeaching hospital. PatientsA total of 1022 IVF-ICSI cycles, frozen embryo transfer excluded. Intervention(s)Patients-all types of responder – underwent IVF with agonist or antagonist protocols. Clinical outcomes of IVF were analyzed according to plasma P levels. Main outcome measure(s)Ongoing pregnancy rates. ResultsWe proposed a serum P level of 1.57ng/ml on day of hCG as a threshold for all types of responders and all protocols combined. Ongoing implantation rates were not affected by elevated progesterone. Live birth rate was inversely associated with serum P levels on day of hCG and more miscarriages were associated with P>1.57ng/ml. We have not found the progesterone>1.57ng/ml on the day of hCG as a prognostic factor for pregnancy. Conclusion(s)Elevated P level on the day of hCG administration negatively influence live birth rate and is correlated to an increase of miscarriage. The detrimental effect of P elevation on pregnancy seems not to be related substantially to endometrium receptivity. Thus, despite a comparable clinical pregnancy rate and an initial implantation rate, we demonstrate more spontaneous abortion and it would seem that the effect of progesterone is later.

Association of follicular fluid volume with membrane stretchability of human metaphase II oocytes following the gonadotropin-releasing hormone agonist protocol during intracytoplasmic sperm injection.

PurposeThe authors previously revealed the association of the follicular fluid (FF) volume with oolemma stretchability following the gonadotropin‐releasing hormone (GnRH) antagonist protocol during intracytoplasmic sperm injection (ICSI). However, the impact of the GnRH agonist protocol on oolemma stretchability remains unclear.MethodsData that were obtained from 74 ICSI cycles were reviewed retrospectively. Controlled ovarian stimulation was performed in accordance with the short GnRH agonist protocol. Each follicle was individually aspirated and assigned to one of six groups, according to the FF volume. The oolemma stretchability during ICSI was evaluated by using a mechanical stimulus for oolemma penetration; that is, oolemma penetration with or without aspiration (high vs low stretchability, respectively).ResultsThe incidence of low oolemma stretchability was significantly higher in the <1.0 mL group than that in the ≥1.0 mL group. The normal fertilization rate was significantly lower in the <1.0 mL group than that in the 2.0‐<3.0 mL group. The rate of blastocyst development was lower in the <1.0 mL group than that in the 3.0‐<4.0 mL group.ConclusionThe FF volume potentially was associated with metaphase II oolemma stretchability, fertilization, and blastocyst development.

Low dose clomiphene citrate as a mild stimulation protocol in women with unsuspected poor in vitro fertilization result can generate more oocytes with optimal cumulative pregnancy rate

BackgroundThe use of long protocol during controlled ovarian stimulation for assisted reproduction attracts high dosage of gonadotropins. High dose of gonadotropins can be detrimental to oocyte development, which affects its quality and compromises the treatment outcome. Mild stimulation protocols that attract low dose gonadotropins could be useful alternative regimen to address such problems. This study evaluated the efficacy of low dose clomiphene citrate based protocol plus low dose gonadotropins on predicted normal responder patients who had unsuspected poor in vitro fertilization (IVF) result, following an initial stimulation with long gonadotropin-releasing hormone (GnRH) agonist protocol.MethodsThis a retrospective study of 65 infertile women who underwent 130 cycles in our center from January 2011 to December 2014. The initial IVF cycle (Group 1) was treated with long GnRH-a protocol plus a high dose of gonadotropins (≥150 IU/d), while second IVF cycle (Group 2) had low dose clomiphene citrate based protocol plus low dose gonadotropins (75–112.5 IU/d).ResultsThe rate of cumulative pregnancy/started cycle (9.2% [6/65] vs. 51% [33/65]; P < 0001) was significantly better in CC protocol than the long GnRH agonist protocol. The number of oocytes retrieved was also higher in CC protocol compared to the long protocol (7.26 ± 1.95 vs. 5.98 ± 1.31; P = 0.03). There was a lower number of patients without embryos (12.31% vs. 33.85%; p < 0.0001) in CC protocol than long protocol.ConclusionsThis study showed a better cumulative pregnancy rate in the low dose CC based protocol. There was a higher number of oocytes retrieved after using a lower total dose of recombinant FSH in CC protocol. Thus, clomiphene treatment plus low dose rFSH can be an alternative option for such patients in second cycle stimulation instead of repeating long protocol regimen. Randomized controlled studies with larger number of patients will be needed for more accurate evidence.

Is Oocyte Quality During IVF Reduced in PCOS? [2B

INTRODUCTION: Determine whether oocyte morphology during IVF is different in women with polycystic ovarian syndrome (PCOS) compared to normal controls. (NC). METHODS: 362 IVF cycles in PCOS women and 268 IVF cycles in normal controls (NC) between the ages of 25-35 were selected from 2012 to 2016. PCOS women were selected using Rotterdam criteria. In addition, all PCOS patients had AMH &gt; 5 ng/mL. Normal controls had normal serum total testosterone &lt; 50 ng/dL, FSH &lt; 12 IU/mL, AMH &lt; 5 ng/mL and normal ovaries on transvaginal ultrasound. Semen analysis was &gt; 14 million/ml with motility. Patients received antagonist or agonist protocol. Oocytes were evaluated by CNY embryologists 4 hours after retrieval. Six categories were defined-metaphase II (MII) good, MII fair, MII poor, metaphase I (MI), germinal vesicle (GV), and degenerated. RESULTS: 6224 oocytes from PCOS women and 3119 oocytes from NC women were studied. The percentage of MII good (39.3 vs 36.5%; p=0.21), fair (24.5 vs 28.0%; p=0.054), and poor (13.3 vs 12.7%; p=0.67) oocytes was not different in PCOS and NC. The percentage of MI (6.34 vs 5.61%; p=0.33), GV (8.09 vs 8.99%; p=0.35), and degenerated oocytes (8.17 vs 7.25%, p=0.28) was not different in both groups. The fresh cycle live-birth rate (# births/cycle) was not different in PCOS women compared to NC (36.7 vs 31.7%, p=0.19). CONCLUSION: Oocyte morphology and live-birth rate during IVF was not different between PCOS women and NC. This suggests that oocyte quality in PCOS women is not reduced.

Ultrasound-guided follicle aspiration at time of laparotomy in a patient with Mayer-Rokitansky-Küster-Hauser syndrome

To demonstrate a unique case of direct ultrasound-guided follicle aspiration at time of a laparotomy in a patient with Mayer-Rokitansky-Küster-Hauser Syndrome. Video presentation. Academic fertility center PATIENT(S): A 32-year-old gravida 0 with Mayer-Rokitansky-Küster-Hauser Syndrome and bilateral ovarian masses presented as a fertility preservation consult from gynecologic oncology due to the possibility of bilateral oophorectomy. Due to the appearance and size of the left ovary oncology planned to perform an exploratory laparotomy and left oophorectomy, with possible right oophorectomy. The patient and her partner desired embryo cryopreservation with plans for future use in a gestational carrier. She had previously undergone vaginal dilator therapy, however her ovaries were inaccessible transvaginally due to their cephalad location and small caliber of the vaginal pouch. The plan was made to proceed with controlled ovarian stimulation and concurrent ultrasound-guided follicle aspiration of the right ovary at the time of laparotomy following left oophorectomy. Ultrasound-guided follicle aspiration invivo at time of laparotomy. Successful controlled ovarian stimulation, oocyte retrieval and embryo cryopreservation. The patient underwent a long agonist protocol and received a total of 2,525 units of gonadotropin with a peak estradiol of 3,264 pg/ml. She required a total of 9 days of stimulation. The normal right ovary responded as expected, and the left ovary remained unchanged. Following laparotomy and left oophorectomy, direct application of the transvaginal ultrasound probe was used to aspirate all visible follicles on the right side invivo. Twenty-four oocytes were retrieved, 15 were mature and 5 blastocysts were cryopreserved. Final pathology of left ovary returned as serous cystadenoma. The right ovary was examined by gynecologic oncology prior to and following retrieval and was thought to be normal and remained in situ. Although the approach described here is not feasible in most cases, this video demonstrates a unique and successful fertility preservation technique by direct ultrasound-guided follicle aspiration invivo at the time of laparotomy in a Mayer-Rokitansky-Küster-Hauser Syndrome patient and to our knowledge, is the first description of its kind. This retrieval would have otherwise been limited by lack of access transvaginally and limited visualization transabdominally. This combined approach should be considered in future patients with müllerian anomalies and similar complicating factors necessitating laparotomy.

The effects of superovulation with gonadotropins on autoantibody levels in patients undergoing assisted reproductive cycles.

To evaluate the effect of controlled ovarian stimulation (COH) with gonadotropins on the serum levels of autoantibodies in the women who underwent in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles and to compare basal levels of these autoantibodies between groups according to history of COH. This prospective cohort study was performed from October 2014 to March 2016 in the Royan Institute. The volunteered infertile women with regard to the inclusion criteria, who underwent IVF/ICSI cycles, were recruited. The COH was performed according to standard long GnRH agonist protocol. The mean levels of the autoantibodies including anti-nuclear, anti-smooth muscle, anti-ovarian, anti-mitochondrial, anti β2-glycoprotein I, anti-parietal cell and anti-follicle-stimulating hormone antibodies were measured at three time points: on the 3-5days of the menstrual cycle, 1week after starting of COH and the ovum pick-up (OPU) day. Of all participants (n = 189), 73 women had history of COH (group B) and 116 women did not have such history (group A). The analysis indicated that the autoantibodies changes during COH were similar in both groups. COH has no significant impact on the level of autoantibodies during the stimulation cycle. Multiple logistic regression analysis showed that the serum levels of anti-smooth muscle antibody on OPU day was the positive predictive factors for live birth following ART cycles in the studied population. No significant effect of COH on the studied autoantibodies by the time of OPU was found but further studies are required to interpret these results.

Does the type of GnRH analogue used, affect live birth rates in women with endometriosis undergoing IVF/ICSI treatment, according to the rAFS stage?

Since the introduction of gonadotropin-releasing hormone (GnRH) antagonists, an extensive amount of literature investigating the role of the downregulation protocols on pregnancy outcomes has been published. However, these studies were mainly performed in the general infertile population where patients with endometriosis were often excluded or underrepresented. This study is a large retrospective cohort study including 386 endometriosis patients undergoing IVF/ICSI, who had been previously classified according to the rAFS system. Patients were stimulated either a long GnRH agonist or GnRH antagonist protocol. Depending on endometriosis stage, patients were divided into two groups: endometriosis stage I–II and endometriosis stage III–IV. Each group was subdivided, based on the type GnRH analog used. When comparing the GnRH agonist and antagonist groups, patients with endometriosis stage I–II, had a tendency toward higher β-hCG positive, clinical pregnancy, and live birth rates (42.8% vs. 26.7%; p = .07) in favor of GnRH agonist use. In endometriosis stage III–IV, no differences were observed between agonist and antagonist cycle in any of the pregnancy outcomes. Multivariate regression analysis did not reveal any significant predictor of live birth after adjusting for relevant confounders. Based on our findings, the chance to have a liveborn in endometriosis population seems not to be affected by the type of GnRH analog used, at least in advanced stages. Findings from stage I–II endometriosis cases merit consideration and further evaluation in a larger sample size is warranted.

The effect of intrauterine human chorionic gonadotropin flushing on live birth rate after vitrified-warmed embryo transfer in programmed cycles: a randomized clinical trial.

To assess the influence of intrauterine human chorionic gonadotropin (hCG) before embryo transfer on the clinical pregnancy and live birth rates after vitrified-warmed embryo transfer (ET) in programmed cycles. This study was a single-blind randomized clinical trial for eligible patients underwent frozen ET cycles with long-term hormonal GnRH agonist protocol for endometrial preparation. Immediately prior to ET, the women were randomly divided into three groups. In the experimental group, 7-10min before embryo transfer, 500IU of hCG with a 40μL of culture medium was injected into the uterus. In the first control (sham) group, 7-10min before ET just 40μL of culture medium intrauterine was infused. In the second control group, no intervention was done. The pregnancy outcomes were compared in the three groups using appropriate statistical tests. Finally, 180 patients allocated into three groups. There was no significant difference in terms of patients 'characteristics among three groups. No significant difference was found in terms of clinical pregnancy among three groups. The miscarriage rate in control group (0%) was significantly lower than those of in the sham and hCG groups (9.8% and P = 0.01, 6.6% and P = 0.04, respectively). In addition, live birth rate (39.3%) in control group was significantly higher than those of in the sham and hCG groups (16.4% and P = 0.005, 23% and P = 0.051, respectively). It was found that intrauterine injection of 500IU hCG before vitrified-warmed ET at cleavage stage has no beneficial effect on pregnancy outcome and is not suggested. NCT02355925.

Comparison of antagonist mild and long agonist protocols in terms of follicular fluid total antioxidant capacity

ObjectiveA high dose of prolonged gonadotropins can yield higher numbers of oocytes and embryos. The high dose or prolonged regimens can be associated with ovarian hyperstimulation syndrome (OHSS), multiple gestations, emotional stress, economical burden and treatment dropout. In mild stimulation lower doses and shorter duration times of gonadotropin are used in contrast to the conventional long stimulation protocol in IVF. It has been proposed that supraphysiologic levels of hormones may adversely affect endometrium and oocyte/embryo. Also it has been proposed that oxidative stress (OS) may alter ovarian hormone dynamics and could be further affected by additional exogenous hormonal stimulation. Therefore our aim was to compare follicular fluid total antioxidant capacity (TAC) in antagonist mild and long agonist stimulations. Materials and MethodsForty patients received antagonist mild stimulation, starting on the 5th day of their cycle and forty patients received long agonist treatment. Seventy-five patients undergoing their first IVF cycle were included in the final analysis. Follicular fluid (FF) samples were analyzed for estradiol (E2), antimullerian hormone (AMH) and TAC. ResultsFF-Total antioxidant capacity (TAC) levels were higher in the long agonist group as opposed to the antagonist group [1.07 ± 0.04 mmol Trolox equivalent/L vs 1 ± 0.13 mmol Trolox equivalent/L] (Fig. 1). Pregnancy rates were not significantly different between the two treatments. The FF-TAC levels were not different among infertility etiologies (Fig. 3). FF-TAC levels did not have a direct correlation with pregnancy but a positive correlation with the total gonadotropin dose was observed. ConclusionPatients with good ovarian reserves and under the age of 35 effectively responded to mild stimulation treatment. Using lower amounts of gonadotropin, yielded less FF-TAC levels in patients who underwent antagonist mild protocol. In patients under the age of 35, antagonist mild stimulation is a patient friendly and effective procedure when undergoing their first IVF cycle.

Pregnancy outcome in delayed start antagonist versus microdose flare GnRH agonist protocol in poor responders undergoing IVF/ICSI: An RCT

Over the years, many article on different aspects of pathogenesis and management of poor ovarian responders have been published but there is no clear guideline for treating themyet. This study was designated to compare the effectiveness of a delayed start protocol with gonadotropin-releasing hormone (GnRH) antagonist and microdose flare-up GnRH agonist protocol in poor ovarian responders. This randomized clinical trial consisted of 100 poor ovarian responder women in assisted reproductive technologies cycles. They were divided randomly in delayed-start antagonist protocol (with estrogen priming followed by early follicular-phase GnRH antagonist treatment for 7 days before ovarian stimulation) and microdose flare-up GnRH agonist protocol. The main outcome was clinical pregnancy rate and second outcome was the number of retrieved oocytes, mature oocytes, 2PN number, fertilization rate, and implantation rate. Fertilization rate, clinical pregnancy rate, and ongoing pregnancy rates were not significantly different between the two studied protocols. Number of retrieved oocytes (5.10±3.41 vs. 3.08±2.51) with p=0.002, mature oocytes (4.32±2.69 vs. 2.34±1.80) with p=0.003, number of 2PN (3.94±1.80 vs. 2.20±1.01) with p=0.001 and implantation rate (19.40% vs. 10.30%) with p=0.022 were significantly higher in delayed antagonist group. The delayed-start protocol can improve ovarian response in poor responders by stimulating and synchronizing follicle development.

Cumulative live birth rates per oocytes retrieved cycle: evaluation of clinical outcomes of IVF/ICSI

Objective: Using of cumulative live birth rate (CLBR) per oocytes retrieved cycle, to assess the clinical outcomes of in vitro fertilization or intracytoplasmic sperm injection (IVF/ICSI) , and to explore impact factors on CLBR following utilization of all fresh and frozen embryos in one complete IVF/ICSI cycle using gonadotropin-releasing hormone (GnRH) agonist, GnRH-antagonist and clomiphene mild stimulation protocols. Methods: Of the patients who underwent IVF/ICSI from January 1st, 2014 to December 31st, 2015 in the First Affiliated Hospital, Nanjing Medical University, a total of 6 142 oocytes retrieved cycles were included. The clinical and laboratory parameters of different ovarian stimulation protocols, and the effects of the age, number of oocytes retrieved and number of embryos available on the CLBR of each oocytes retrieved cycle were analyzed. Results: The CLBR was 69.0% (2 004/2 906) in the GnRH-agonist protocol versus 67.4% (644/955) in the GnRH-antagonist protocol (P>0.05); the CLBR of clomiphene mild stimulation protocol was 53.2% (1 215/2 281) , significantly lower than those of the other two protocols (all P<0.05). The CLBR significantly decreased with age increased. When divided into four groups according to the patients' age, we found that CLBR were not statistically significant using three different protocols in the 20-25 years old group (all P>0.05). There was a strong association between the number of oocytes retrieved and embryos available on CLBR. CLBR rose significantly with an increasing number of oocytes up to 6, then the rising trend slowed down. Patients were categorized into four groups according to the number of oocytes retrieved, CLBR was significantly higher using GnRH-antagonist protocol (50.0%) than mild stimulation protocol (37.0%) in low ovarian responder (0-4 oocytes) group (P<0.05) . The CLBR were no significant difference among three protocols in normal (10-15 oocytes) and high responders (≥15 oocytes) group (all P>0.05) . The incidence rate of ovarian hyperstimulation syndrome in GnRH-agonist protocols (5.2%, 152/2 906) were significantly higher than those of GnRH-antagonist (4.4%, 42/955) and clomiphene mild stimulation protocols (1.5%, 34/2 281; all P<0.05) . Conclusions: CLBR is an important index to assess the clinical outcomes of IVF/ICSI. Age, number of oocytes retrieved and embryos available could affect CLBR obviously. According to the different age and ovarian response of patients, we should design ovarian stimulation protocols based on target oocytes number in order to get higher CLBR and reduce complications.

Progesterone level on the day of triggering and pregnancy outcome in long GnRH agonist protocol

Progesterone level on the day of triggering and pregnancy outcome in long GnRH agonist protocol

The effect of coasting on the outcome of intracytoplasmic sperm injection: comparable analysis of GnRH agonist and antagonist cycles

Introduction: One of the preventive strategies in case of impeding ovarian hyperstimulation syndrome (OHSS) is coasting. The aim of this study was to compare the effect of coasting in high responder patients treated with gonadotropin-releasing hormone (GnRH) agonist or GnRH antagonist protocol for intracytoplasmic injection and embryo transfer. Materials and Methods: This retrospective study was conducted in the infertility unit in a private hospital. The study group included women who underwent an intra-cytoplasmic sperm injection (ICSI) cycle with a coasted period during ovulation induction from 2006 to 2013. The cycles outcome of cycles were compared between GnRH agonist (n=226) and GnRH antagonist (n=110) coasting cycles. Results: Women's age and other baseline characteristics of the groups were similar. Coasting was significantly more required in GnRH agonist cycles compared to GnRH antagonist cycles (11.8% vs. 4.5%, respectively, OR = 2.63, p p = 0.903). Moderate-severe OHSS occurred in 13 (5.7%) cases in the GnRH agonist group and three (2.7%) cases in the GnRH antagonist group (p = 0.343). In the GnRH agonist group, the longer duration of coasting (≥ four days) was associated with the lowest live birth rate (27.2%), but it did not reach a statistical significance. Conclusions: Live birth and moderate/severe OHSS rates are similar in the GnRH agonist and the GnRH antagonist cycles with coasting. Despite the lack of statistical significance, ≥ four days of coasting is related to the lowest live birth rate through ICSI compared to < four days of coasting in the GnRH agonist cycles.

Serum progesterone concentrations before and after human chorionic gonadotropin triggering and invitro fertilization : Intracytoplasmic sperm injection cycle outcome in long gonadotrophin releasing hormone agonist protocol

Objective: To assess the impact of serum progesterone concentrations before and after HCG triggering on IVF/ICSIcycle outcomes in long GnRHa protocol.Patients and Methods: This is a single-center prospective observational cohort study, in which 102 IVF/ICSI patients with normal cycle day 2 basal hormones were recruited and underwent ovarian stimulation using the long GnRHa protocol. Serum progesterone on the day of HCG trigger; one day after, progesterone/estradiol was assessed and correlated with pregnancy rates, the total dose of used gonadotropins, serum estradiol level on day of trigger, the number of collected oocytes, the number of metaphase II oocytes and the quality of transferred embryos.Results: 96 women were included in the analysis. In our study, the receiver-operating characteristic (ROC) analysis was used to gain more diagnostic accuracy. Our data according to ROC analysis showed that the P levels on the day of hCG trigger, and its levels one day after and P/E2 on the day of hCG trigger had no role in prediction of clinical pregnancy rates. There was significant correlation between the serum progesterone levels before and after HCG triggering with the total dose of gonadotropins used. They also correlated strongly with serum estradiol level on day of trigger, the number of collected oocytes and the number of metaphase II oocytes.Conclusion: Peri-ovulatory serum progesterone concentrations cannot predict pregnancy rates in IVF/ICSI cycles using long GnRHa protocol.

Empty Follicle Syndrome: A Challenge to Physician.

Background:Empty follicle syndrome (EFS) is a condition in which no oocytes are retrieved from normally growing ovarian follicles after ovarian stimulation. It is a rare and frustrating condition of obscure etiology.Objective:The objective of this study was to estimate the incidence of EFS and study factors related to it.Design:This was a retrospective study.Setting:This study was conducted in hospital-based research center.Methods:In 1968 in vitro fertilization cycles from January 2010 to August 2016 were studied. Agonist, antagonist, and miniflare protocols were used for the stimulation.Results:The incidence of EFS is 2.38% (47/1968 cycles). Antagonist protocol group (76.59%, n = 36) had highest incidence of EFS (6.69%). Literature on EFS depicts decreased ovarian reserve (DOR) as the main cause, but only 4.25% of patients had DOR in our study. Interestingly, polycystic ovary syndrome and unexplained infertility were found in 31.9% of the cases. Serum anti-Müllerian hormone (AMH) levels (mean ± standard deviation [SD]) were 4.47 ± 3.54 ng/ml, and antral follicle count (AFC) was 15.30 ± 8.07 (mean ± SD) emphasizing that diminished ovarian reserve is not the main factor for EFS. All patients (n = 95) who underwent ovum pickup on day when any patient had EFS were taken as control. Patients with EFS were compared with controls. A statistically significant difference was not observed in serum AMH (P = 0.38) and AFC (P = 0.52).Conclusion:EFS is an uncommon event. Antagonist cycles have higher chances of empty follicle at ovum pickup. Looking at the profile of patients in this study, we conclude that EFS is not a manifestation of DOR.

Ultrasound and hematological changes during early luteal phase in women at high risk for developing ovarian hyperstimulation syndrome.

To assess ultrasound and hematological changes during the early luteal phase following triggering of final oocyte maturation with human chorionic gonadotropin (hCG) in women at high risk for developing ovarian hyperstimulation syndrome (OHSS). This was a retrospective cohort study of 319 women undergoing in-vitro fertilization who were at high risk for OHSS following administration of hCG for the triggering of final oocyte maturation. Patients were treated with a gonadotropin-releasing hormone agonist or antagonist protocol and were monitored for 5 days post-oocyte retrieval (early luteal phase). Severe OHSS was diagnosed in the presence of at least moderate ascites and two or more of the following: maximum ovarian diameter (MOD) > 100 mm, hematocrit (Ht)> 45%, white blood cell count (WBC) >15 000/mm3 , hydrothorax, dyspnea and oliguria. Outcome measures included change in Ht, ascites grade, WBC and MOD, as well as the association between these changes during the early luteal phase. Ascites grade, Ht and WBC increased significantly (P ≤ 0.001) during the early luteal phase, both in patients who developed and in those who did not develop severe early OHSS. MOD increased significantly (P = 0.001) only in patients who developed severe early OHSS. On multivariable analysis, both time following oocyte retrieval and whether severe early OHSS developed were significantly associated with ascites grade, Ht, WBC and MOD; furthermore, there was also a significant interaction between time and development of severe early OHSS for all four variables (P ≤ 0.001). In women at high risk of OHSS, ascites grade, Ht and WBC significantly increased with time over the 5-day observation period, in line with the pathophysiology of the syndrome. Our data support the use of MOD in the diagnosis of severe early OHSS, and provide novel evidence for the role of change in Ht as a patient-specific hemoconcentration marker during development of OHSS. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

ICSI Yapılan Endometrioması Olan Kadınlarda Long Agonist veya Short Antagonist Protokol: Retrospektif Analiz

ICSI Yapılan Endometrioması Olan Kadınlarda Long Agonist veya Short Antagonist Protokol: Retrospektif Analiz

Case Report of Ectopic Pregnancy during Controlled Ovarian Stimulation without Oocytes Harvested and Late Ovarian Hyperstimulation Syndrome

Here we reported a rare case of misdiagnosed ectopic pregnancy (EP) due to unintended ovulation during controlled ovarian stimulation (COS) in GnRH agonist cycle, resulting in no oocytes harvested and late hyper-stimulation syndrome (OHSS). The patient was a 33-year old primary infertile woman due to male’s factors and underwent her second in vitro fertilization (IVF) cycle using GnRH agonist protocol, and no oocytes harvested on ovum picked-up (OPU) day. The start of gonadotropin usage was on day 8th of her period, and the P level increased rapidly and strangely high from day 8th after gonadotropin usage. The E2 level and follicles grew normally but finally no oocytes harvested. She was diagnosed as late ovarian hyper-stimulation syndrome (OHSS) 7 days after OPU. 20 days after OPU, no menstruation come and a positive urine test of hCG were reported. And the patient was diagnosed as EP by laparoscopy. In conclusion, rapidly increased P level, no oocyte retrieval and late onset of OHSS should be very important clues to diagnose this misdiagnosed EP.

A case report on severe ovarian hyperstimulation syndrome in a pregnancy with torsion of bilateral enlarged ovaries with acute abdomen

Ovarian hyperstimulation syndrome is a complication of fertility treatment, which uses pharmacological ovarian stimulation to increase the number of oocytes and therefore embryos available during assisted reproductive technology. Ovarian hyperstimulation syndrome is invariably associated with increased volume of ovaries which is itself a threat to undergo torsion, and it may cause an additional threat requiring prompt surgical intervention in many situations. Simple release of torsion, sacrificing the devitalized ovarian tissue in part and complete can have effect in continuation of pregnancy; and something like this happened in our case. The patient, 29-year-old, a known case of polycystic ovary syndrome (PCOS), conceived through ovulation induction; came with an episode of acute pain abdomen with abdominal distension toward the later part of her first trimester. Ultrasonography was done. Bilateral enlarged ovaries of around 23 cm × 11.8 cm each were seen meeting at the pouch of Douglas with ascites. It was a case of ovarian hyperstimulation syndrome, more specifically, a case of late ovarian hyperstimulation syndrome. Serum E2 level was 3263 pg/ml. Laparotomy was then done. Intraperitoneally bilateral ovarian torsion was seen with areas of necrosis. The right oophorectomy was done, while on the left side some portion of normal ovarian tissue was preserved. Following the operation, her symptoms were improved. The pregnancy continued uneventfully. Exposure of ovaries to human chorionic gonadotropin or luteinizing hormone following controlled ovarian stimulation by follicle-stimulating hormone underlies most cases of ovarian hyperstimulation syndrome. The risk of ovarian hyperstimulation syndrome is smaller when using gonadotropin-releasing hormone antagonist (GnRH) antagonist protocol instead of GnRH agonist protocol for suppression of ovulation during ovarian hyperstimulation. To avoid ovarian hyperstimulation syndrome, the best trigger is GnRH agonists. In PCOS patients, metformin is an important aid in reducing ovarian hyperstimulation syndrome.

Same Cycle Shift from IVF with Own Oocytes to Oocyte Donation in No or Poor Response Cycles.

Our In-Vitro Fertilisation Centre is situated in a large developing country, Madagascar, with very bad roads and low income patients. Therefore we try to find ways to reduce as much as possible the number of attempts to obtain a pregnancy. Poor or no response to ovarian stimulation in In Vitro Fertilization (IVF) cycles is a great challenge. Here we describe a method whereby we shift from IVF to Oocyte Donation (OD) during the same cycle for patients whose ovaries do not respond properly to ovulation stimulation. Patients were superovulated with a long protocol agonist treatment and ultrasonically monitored for IVF/ICSI. When, at half way of the stimulation, it was clear that there was a no or poor response, gonadotropin administration was stopped and immediately replaced by estrogens; when the endometrium was considered to be sufficiently receptive, some donated oocytes from our concomitant oocyte donation (OD) program were fertilized with the patient's husband sperm and progesterone was added to the patients' treatment. After 48 hours the resulting embryos were transferred. Five poor responders patients underwent the described procedure. Three conceived, one of which aborted at 9 weeks, while the other two are ongoing. These patients signed the consent form accepting the possibility to shift from IVF to OD during the same cycle and three clinical pregnancies were obtained. OD through this technique seems more acceptable by poor responders than planned OD. This is a preliminary report and to our knowledge it is the first report of such a method.