hMG Ampoules Research Articles

P-359 Effect of estradiol pretreatment on antagonist ICSI cycles outcome

Abstract Study question Does estrogen pretreatment in antagonist ICSI cycles improves the outcome? Summary answer Pretreatment with estrogen in antagonist cycles reduced the days of stimulation, the number of hMG ampoules and enhanced the implantation rate. What is known already It has been previously reported that, programming of antagonist cycles with E2 only, started in the luteal phase and continued beyond the menses till the first day of stimulation, yielded similar results as the long agonist protocol. E2 pre-treatment in the luteal phase has an inhibiting role on follicular growth through its negative feedback on the FSH increase during the luteal follicular transition phase. This effect stops as soon as E2 administration is terminated. Study design, size, duration This was a prospective randomized controlled trial performed in a private IVF centers from June 2020 to February 2021. One hundred and fourteen infertile couples undergoing intracytoplasmic sperm injection embryo transfer cycles (ICSI-ET) were included. Participants/materials, setting, methods Group A includes 57 patients were pretreated with a dose of 4 mg estradiol valerate (progynova 2 mg; Bayer) once daily starting 10days before expected menses. Ovarian stimulation was started one day after the last estradiol dose, in a dose ranging from 225 to 375 IU of hMG. While in group B , 57 patients received stimulation in a dose of 225 to 375 IU of hMG starting on cycle day 2 without estradiol pretreatment. Main results and the role of chance The daily dose of hMG was significantly lower in The study group (P = 0.048), the stimulation days were significantly higher in the control group (P = 0.049), the total number of hMG ampoules was significantly higher in the control group (P = 0.041), and the implantation rate was higher in the study group (P = 0.045) , also the pregnancy rate (positive pregnancy test) was higher in the study group (p = 0.044) but there was no significant statistical difference detected as regards the clinical pregnancy rate between both groups (P = 0.180) , the serum estradiol on day of hCG ( p = 0.055), serum progesterone level on hCG day (P = 0.71) and the endometrial thickness (p = 0.780) . Also there is no significant statistical difference between the two groups as regarding number of follicles on day of hCG. (P = 0.803), the number of mature oocytes (P = 0.703) and no significant difference in the number of good quality embryos (p = 0.532) and the ratio of mature oocytes to number of follicles on day of hCG (P = 0.835), with no significant statistical difference between both groups. Limitations, reasons for caution The limitation of this study is the small number of patients as we included only 114 patients. Wider implications of the findings Luteal estradiol in antagonist cycles improved the outcomes of ICSI procedure by reducing the number of gonadotropin ampoules used for COH and reduced duration of stimulation, also the implantation rate is improved by luteal estradiol administration. Trial registration number NCT05197374

GnRH agonis short protocol versus GnRH antagonist flexible protocols in poor responder undergoing in vitro fertilization treatment.

Objective: To compare the short agonist and flexible antagonist protocols in the management of poor responders to standerd long down regulation protocol. Design: Randomized prospective comparative study. Setting: private IVF center(Engab). Patient(s): One hundred poor-responder (IVF)(ICSI), who responded poorly to the standerd long down- regulation protocol in their first treatment cycle. Intervention(s): Peak serum E2 was assayed on the day of hCG administration. Main Outcome Measure(s): primary outcome: number of HMG ampoules used, peak E2 at the triggering day, number of oocytes retrieved, number of metaphase II oocytes, fertilization rate, embryo quality and number of embryos transferred.cycle cancellation. secondary outcome: pregnancy rate , miscarriage rate . Result(s): GnRH-antagonist protocol shows increased – non significant- pregnancy rate and decreased - non significant - miscarriage rate than agonist short protocol, however agonist short protocol appears to be more effective than the GnRH-antagonist protocol in terms of number of FSH ampules, peak E2 level, fertilization rate, and top-quality embryos transferred in poor-responder. Conclusion(s): The probability of pregnancy might be better with the use of the antagonist protocol, also flexible antagonist protocol is a simpler and more patient friendly method of ovarian stimulation compared with the short agonist protocol.

Comparison of the Microdose Flare Up GnRH Agonist and Antagonist Protocol in Assisted Reproduction with Poor Ovarian Response during Controlled Ovarian Stimulation Cycles

Background: Poor ovarian response presents a significant challenge in artificial reproductive treatment (ART). Poor responders are estimated to comprise approximately 9- 24% of IVF cycles patients. Recently, the development of protocol offered another approach for ovarian stimulation by blocking the pituitary receptors. There is evidence that application of protocol decreases the duration of ovulatory stimulus and reduce incidence of ovarian hyperstimulation syndrome (OHSS). Objectives: The aim of the current study was to evaluate the effect of the protocol to the microdose flare up agonist protocol for poor ovarian responders undergoing IVF/ICSl treatment. Patients and Methods: A total of sixty patients of IVF/ICSI assigned to be poor responders were randomized into two groups; group 1 Thirty patients received fixed protocol and group 2 thirty patients received a microdose flare up agonist protocol. Patients characteristics and treatment outcomes were statistically compared between groups. Results: Duration of stimulation was highly significantly lower in the group than that of the microdose flare up one (antagonist 8.60±1.63 versus microdose flare up 12.06±2.86; p=0.001). Number of ampoules of HMG was highly significantly lower in the group than that of the micro dose flare up agonist one (antagonist 23.53±7.33 versus micro dose agonist 71.97±9.35; p=0. 001). The number of oocytes retrieved in the group was not different from microdose flare agonist group (5.14±2.45 vs. 5.11±1.29; p=0.953), and the number of embryos transferred was similar in both groups (2.03±0.08 vs. 2.09 ± 1.05; p=0.674). No significant differences in pregnancy rates were reported. Conclusion: we offer using the GnRH antagonist as a patient friendly protocol in ART with poor ovarian response with Immediate mode of action, similar pregnancy rate, time saving, less duration of stimulation and number of ampoules for stimulation than microdose flare up protocol.

Effect of Cholesterol Lowering Agent ( Lipolax ) on Some Physiological Parameters in Some Infertile Obese PCOS Egyptian Women Undergoing ICSI

Background: Infertile obese women with polycystic ovary syndrome (PCOS) is a common endocrinopathy affecting women and characterized by hyperandrogenism, chronic anovulation with either oligomenorrhea or amenorrhea and hyperandrogenism, and its morbidity may include hyperinsulinemia, insulin resistance. Lipolax was used to enhance the ovulation response especially when beginning the intra cytoplasmic sperm injection (ICSI) protocol. This study aimed to enhance the sexual hormones, lipid profile, ovulation response and pregnancy outcome in infertile obese PCOS women's treated with Lipolax drug (fenofibrate) before undergoing to ICSI. Setting: This study was conducted in International Islamic Center for Population Studies and Research-Assisted Reproduction Unit, Al-Azhar University during the period between 2009 and 2011. Patients and Methods: A total number of 75 infertile patients with obese PCOS were randomized to receive oral Lipolax (fenofibrate) for three months before undergoing to ICSI. For each patient FBS and Hb, hormonal profile included FSH, LH, FSH/LH ratio, E2, PRL and lipid profile evaluation were performed at baseline and after 3 months of treatment. Results: There was a significant decrease in the FBS, in cases treated with Lipolax when compared with control or obese PCOS, no significant differences were noticed in the level of Hb% in both groups. Total lipids, triglycerides and total cholesterol decreased significantly compared with obese PCOS group. Significant decrease was also observed in respect to LDL in cases of Lipolax treated group than cases of obese PCOS, significant increase in the level of HDL was recorded. A significant enhance was detected in increase FSH hormone level and decrease LH, FSH/LH ratio and E2 hormonal level after Lipolax treatment, no difference was observed in prolactin hormonal profile. Observed improvement was detected in the number of HMG ampoules, mature oocytes, and number of grade A embryos and also in pregnancy outcome. Conclusion: Lipolax (lowering cholesterol agent) improving the response in obese PCOS women undergoing ICSI, by enhance their resistance sensitivity in transadipose tissue leads to improve the function of gonads and sexual hormones and lipids profile which leads to decreased total cost of ICSI by lowering the number of stimulation ampoules and increase mature collected oocytes and finally the percent of successful pregnancy rate.

Effect of Insulin-Sensitizer Drug ( Metformin ) on some Physiological Parameters in some Infertile Obese Egyptian Women Undergoing ICSI

Background: Egyptian infertileobese women with polycystic ovary syndrome (PCOS) were markedly increased in ART Unit for infertility treatment undergoing ICSI. In a trial to enhance the ovulation, fertilization response and pregnancy outcome treated patients with Metformin as insulinsensitizing drug, 3 months before ICSI processing. The aim of this study was to evaluate the effect of Metformin on the hormonal profile, lipid and lipoprotein profile and insulin resistance in obese PCOS patients undergoing ICSI. Setting: This study was conducted at International Islamic Center for Population Studies and Research, Assisted Reproduction Unit, Al-Azhar University during the period between 2009 and 2011. Design: A prospective randomized study. Patient and Methods: A total of 75 patients with obese PCOS were randomized to receive oral Metformin for three months. For each patient, FBS and Hb, hormonal profile included FSH, LH, FSH/LH ratio, E2 and PRL, lipid and lipoprotein profile included total cholesterol, LDL, HDL and triglycerides evaluation were performed at baseline and after 3 months of treatment. Results: There was a significant decrease in the FBS in cases treated with Metformin when compared with control or obese PCOS, no significant differences were noticed in the level of Hb% in both groups. Total lipids, triglycerides and total cholesterol were decreased significantly compared with obese PCOS group. Significant decrease was also observed in respect to LDL in cases of Metformin than cases of obese PCOS. Significant increase in the level of HDL was recorded. Significant decrease was detected in FSH, LH and FSH/LH ratio in Metformin treated group while no difference was observed in prolactin or estradiol hormonal profiles. Observed improvement was detected in the number of received HMG ampoules, mature oocytes, number of grade A embryos and in pregnancy outcome. Conclusion: Metformin as lowering insulin resistance, improving the response in obese PCOS women undergoing ICSI, by enhance their resistance sensitivity in transadipose tissue leads to improvement the function of gonads and hormonal and lipids profile .This improvement was detected by decreased total cost for ICSI, lowering the number of both given stimulation ampoules and mature collected oocytes and finally the percent of successful pregnancy rate.

Sequential letrozole and HMG: a successful novel super ovulation protocol significantly improves pregnancy rate in PCOS patients undergoing ICSI. randomized controlled trial

Sequential letrozole and HMG: a successful novel super ovulation protocol significantly improves pregnancy rate in PCOS patients undergoing ICSI. randomized controlled trial

Comparison of GnRH antagonist with long GnRH agonist protocol after OCP pretreatment in PCOs patients

To evaluate the efficacy of GnRH antagonist in comparison with the GnRH agonist protocol in OCP pretreated polycystic ovary syndrome (PCOs) patients undergoing their first ART cycle. Prospective randomized controlled trial. University-based tertiary fertility center. Ninety-five PCOs patients under 35 years of age, with primary infertility were randomized to an ovarian stimulation protocol consisting of either. GnRh antagonist (study group) or GnRH agonist (control group) after pretreatment with OCP. Coasting or GnRH agonist Trigger was used when estradiol level > or =3,000 pgr/ml in the control and study group, respectively. Both groups received 800 mg vaginal progesterone and 4 mg oral estradiol valerate for luteal phase support. There was no statistically significant difference in the age, body mass index, basal FSH, duration of infertility, the number of oocytes retrieved, the number of embryos transferred, Serum E2 levels on day of trigger, fertilization rate, chemical and clinical pregnancy rates between the two groups. None of the patients in the study group developed ovarian hyperstimulation syndrome (OHSS) compared with 22.2% of patients in the control group. Total duration of treatment and the number of HMG ampoules used were lower in the study group. Antagonist protocol and GnRH agonist trigger for ovulation whenever necessary has a similar cycle outcome to the GnRH-agonist protocol in OCP pretreated PCOs patients, with significantly reduced risk of OHSS.

Metformin in the treatment of clomiphene citrate-resistant women with polycystic ovary syndrome undergoing in vitro fertilisation treatment: A randomised controlled trial

SummaryThis study was conducted to determine the efficacy of metformin vs placebo in women with polycystic ovary syndrome (PCOS) undergoing IVF treatment. A total of 66 CC-resistant patients were studied prospectively. The women were randomly assigned to receive 850 mg of metformin (n = 34) or placebo (n = 32) twice daily that started 1 month before commencing the IVF treatment and continued to the day of the pregnancy test. Compared with the metformin-treated group, women who received a placebo had a significant increase in terms of days of stimulation with HMG, number of HMG ampoules, number of follicles >14 mm, number of oocytes retrieved, number of mature eggs, fertilisation rate and oestradiol level on the day of hCG administration. Similarly, women in the placebo group showed a significant increase in poor quality embryos, cancellation rate and the rate of ovarian hyperstimulation syndrome, as compared with the metformin-treated group. On the other hand, women who received metformin showed a significantly higher number of good quality embryos and implantation rate when compared with the placebo controls. Despite the transfer of a similar number of embryos, an insignificant increased in the pregnancy rate along with significant reduction in the abortion rate was observed in the metformin-treated group as compared with the placebo controls. No fetal abnormalities were encountered in the babies born in the metformin-treated group. It is concluded that metformin affects positively the quality of both oocytes and embryos without a significant increase in the pregnancy rate. It decreases significantly the rates of abortion and ovarian hyperstimulation syndrome.

The role of the follicle stimulating hormone receptors genotype in the response to FSH in women undergoing controlled ovarian stimulation

OBJECTIVE: To investigate the role of follicle stimulating hormone receptor (FSHR) genotype, in response to FSH in women undergoing controlled ovarian stimulation and to examine the association of ovarian response variables with the total HMG dose in different allelic variant genotypes.DESIGN: Prospective clinical trial.MATERIALS AND METHODS: Women undergoing controlled ovarian hyperstimulation were subjected molecular studies DNA isolation, DNA amplification and RFLP analysis. Through this molecular study, the studied women are classified into three groups: Asn680Ser variant, namely, aa (680Asn/Asn), as (680Asn/Ser) and ss (680Ser/Ser), of the FSHR gene. follicular development was monitored by transvaginal ultrasonography after 6 days of stimulation and then every other day. Sonography was performed daily when the leading follicle exceeded 14 mm in diameter. Ovulation was induced by 10,000 IU human CG (hCG), IM, when at least two follicle was 20 mm in diameter. Oocytes were collected by transvaginal Ultrasound-guided aspiration under general anesthesia was generally performed approximately 36 hours after hCG administration. Intracytoplasmic sperm injection was performed in all patients.RESULTS: The frequency distributions of FSHR allelic variants were 20 patients (37%) for the allelic variant (aa), 20 patients (37%) for allelic variant (ss) and 14 patients (26%) for the allelic variant (as) patients. The mean number of HMG ampoules given to the studied patients was 24.6 ± 5.1 in allelic (aa) patients, 41.3 ± 4.8 in allelic (ss) patients, and 37.5 ± 6.3 in allelic (as) patients and showed statistically significant difference (p <.0001). In patients belonging to allelic variant (aa), the larger the HMG dose, the less the oocytes number will the patient develop, the more the E2HCG will the patient produce and the more the MII oocytes that will develop. In patients belonging to allelic variant (ss), the larger the dose of HMG, the more the oocytes number will the patient develop, the more the E2HCG will the patient produce and the more the MII oocytes that will develop. In patients belonging to allelic variant (as), the results are roughly similar to that observed in allelic (aa) group.CONCLUSIONS: We can conclude that a different ovarian response to FSH stimulation do occur, depending on the FSHR genotype and indicates that subtle genetic changes might fine-tune the hormonal regulation of reproduction. knowing the different sensitivity to FSH, depending on the FSHR genotype, could be important to prevent OHSS. OBJECTIVE: To investigate the role of follicle stimulating hormone receptor (FSHR) genotype, in response to FSH in women undergoing controlled ovarian stimulation and to examine the association of ovarian response variables with the total HMG dose in different allelic variant genotypes. DESIGN: Prospective clinical trial. MATERIALS AND METHODS: Women undergoing controlled ovarian hyperstimulation were subjected molecular studies DNA isolation, DNA amplification and RFLP analysis. Through this molecular study, the studied women are classified into three groups: Asn680Ser variant, namely, aa (680Asn/Asn), as (680Asn/Ser) and ss (680Ser/Ser), of the FSHR gene. follicular development was monitored by transvaginal ultrasonography after 6 days of stimulation and then every other day. Sonography was performed daily when the leading follicle exceeded 14 mm in diameter. Ovulation was induced by 10,000 IU human CG (hCG), IM, when at least two follicle was 20 mm in diameter. Oocytes were collected by transvaginal Ultrasound-guided aspiration under general anesthesia was generally performed approximately 36 hours after hCG administration. Intracytoplasmic sperm injection was performed in all patients. RESULTS: The frequency distributions of FSHR allelic variants were 20 patients (37%) for the allelic variant (aa), 20 patients (37%) for allelic variant (ss) and 14 patients (26%) for the allelic variant (as) patients. The mean number of HMG ampoules given to the studied patients was 24.6 ± 5.1 in allelic (aa) patients, 41.3 ± 4.8 in allelic (ss) patients, and 37.5 ± 6.3 in allelic (as) patients and showed statistically significant difference (p <.0001). In patients belonging to allelic variant (aa), the larger the HMG dose, the less the oocytes number will the patient develop, the more the E2HCG will the patient produce and the more the MII oocytes that will develop. In patients belonging to allelic variant (ss), the larger the dose of HMG, the more the oocytes number will the patient develop, the more the E2HCG will the patient produce and the more the MII oocytes that will develop. In patients belonging to allelic variant (as), the results are roughly similar to that observed in allelic (aa) group. CONCLUSIONS: We can conclude that a different ovarian response to FSH stimulation do occur, depending on the FSHR genotype and indicates that subtle genetic changes might fine-tune the hormonal regulation of reproduction. knowing the different sensitivity to FSH, depending on the FSHR genotype, could be important to prevent OHSS.

Impact of estradiol patterns in clomiphene citrate/human menopausal gonadotropin/cetrorelix protocol

The importance of serum estradiol changes associated with gonadotropin-releasing hormone antagonists is not clear. The purpose of the present study was to analyze the impact of estradiol changes after cetrorelix injection on the outcome of intracytoplasmic sperm injection (ICSI) cycles. This was a prospective observational study. One hundred and thirteen women with male-factor infertility who were undergoing first ICSI cycles were reviewed for this study. Excluding seven cycles with incomplete data, 106 cycles were included in the analysis. The women were stimulated with clomiphene citrate and human menopausal gonadotropin (hMG). Cetrorelix acetate (2.5 mg) was given when the leading follicles reached 14 mm. After cetrorelix administration, serum estradiol rose in 48 cycles (45.3%), plateaued in 26 cycles (24.5%) and dropped in 32 cycles (30.2%). Mean age and day-3 follicle-stimulating hormone, luteinizing hormone and estradiol levels were similar among the three groups. The mean ampoules of hMG used, estradiol levels on the day of human chorionic gonadotropin injection and the clinical outcomes, including numbers of oocytes retrieved and fertilization, implantation and pregnancy rates, were similar in all three groups regardless of the trend of estradiol. In conclusion, estradiol patterns after cetrorelix injection show no correlation with clinical outcome and ovarian reserve, and falling estradiol is not associated with adverse outcome.

P-6: Prednisolone Administration in the Luteal Phase in ICSI

Background & Significance: Despite numerous developments in assisted reproduction, the implantation rate of replaced embryos remains low. It was suggested that corticosteroids during the luteal phase may improve implantation in those patients.Objective: The aim of this work was to conduct a randomized controlled study to evaluate prednisolone administration during the luteal phase for patients treated with ICSI.Materials and Methods: A total of 526 patients treated with ICSI in our unit were prospectively randomized into two groups. The first group received 15 mg of prednisolone orally in 3 divided doses following embryo transfer. There were no significant differences between both groups regarding the age, number of hMG ampoules administered, oocytes retrieved or embryos transferred.Results: A total of 66 patients out of 267 became pregnant in the prednisolone group (24.7%) compared to 65 out of 259 in the control group (25.1%) [OR = 0.980 (95% CI = 0.66–1.46)]. A total of 100 embryos implanted in the prednisolone group out of 1075 replaced (9.46%) compared to 90 out of 882 in the control group (10.2%) [OR = 0.903 (95% CI = 0.70–1.22)].Conclusion: Prednisolone does not improve the clinical pregnancy rate or the implantation rate for patients treated with ICSI. However, we have calculated that to improve the clinical pregnancy rate from 25 to 30%, the least number needed to study is 636 patients in each arm, accepting a probability of 80% of detecting a true difference and taking 5% as the level of significance. The work continues. Background & Significance: Despite numerous developments in assisted reproduction, the implantation rate of replaced embryos remains low. It was suggested that corticosteroids during the luteal phase may improve implantation in those patients. Objective: The aim of this work was to conduct a randomized controlled study to evaluate prednisolone administration during the luteal phase for patients treated with ICSI. Materials and Methods: A total of 526 patients treated with ICSI in our unit were prospectively randomized into two groups. The first group received 15 mg of prednisolone orally in 3 divided doses following embryo transfer. There were no significant differences between both groups regarding the age, number of hMG ampoules administered, oocytes retrieved or embryos transferred. Results: A total of 66 patients out of 267 became pregnant in the prednisolone group (24.7%) compared to 65 out of 259 in the control group (25.1%) [OR = 0.980 (95% CI = 0.66–1.46)]. A total of 100 embryos implanted in the prednisolone group out of 1075 replaced (9.46%) compared to 90 out of 882 in the control group (10.2%) [OR = 0.903 (95% CI = 0.70–1.22)]. Conclusion: Prednisolone does not improve the clinical pregnancy rate or the implantation rate for patients treated with ICSI. However, we have calculated that to improve the clinical pregnancy rate from 25 to 30%, the least number needed to study is 636 patients in each arm, accepting a probability of 80% of detecting a true difference and taking 5% as the level of significance. The work continues.

IVF-ET Outcome in Female Genital Tuberculosis

As there are conflicting results concerning the outcome of IVF-ET in female infertility due to tuberculosis tubal factor (TB);this study is the first one aiming to evaluate its results vs. IVF-ET results in non tuberculous tubal factor infertility (NTB). Retrospective study 15 patients with tuberculous tubal factor infertility and a normal uterine cavity underwent 24 cycles of in vitro fertilization between 1995 and 2004. 13 women have had primary infertility and 2 secondary infertility. In all 15 patients the diagnosis of tuberculosis was confirmed histologically during previous laparotomies and/or endometrial biopsy examinations. The primary location of tuberculosis was as following: pleural (1) pulmonary (1) peritoneal, endometrial and/or tubal (12) nodal tuberculosis (1). All patients were treated with antituberculous chemotherapy for 6 to 12 months. The endometrial cavity was assessed by hysterosalpingography and/or hysteroscopy to evaluate its regular shape. An endometrial biopsy was done before the IVF cycle to rule out a current endometrial tuberculosis. The control group is composed of the two cycles of NTB undergoing IVF-ET just before and following each TB IVF-ET cycle. 24 IVF-ET cycles were done in 15 couples with TB, all women had a normal uterine cavity. The control group includes 87 IVF-ET cycles (NTB) in 82 couples. The results show no differences between TB and NTB infertile women for all results except for endometrial thickness (8.7 ± 2 vs. 10.1mm ± 2.5; P=0.01). The other results are respectively for TB (N: 24) vs. NTB cycles (87) as follow: Women’s mean age: 34.1 ± 5.7 vs. 34.8y ± 3.8 (NS) mean ± SD controlled ovarian hyperstimulation (COH): Down regulation = 22 vs. 80; Flare protocol: 1 vs. 6, antagonist protocol (1 vs1); Mean No of HMG ampoules used/cycle = 44.1 ± 13.5 vs. 43.3 ± 15.3 (NS); Mean dose of reFSH used/cycle = 3100 UI ± 1182.9 vs. 2463UI ± 886.2. Mean No of MII oocytes retrieved/cycle = 9.5 ± 4.9 vs. 9 ± 6.5; Mean No of embryos obtained/cycle: 6.2 ± 4.1vs 5.5 ± 4.4 (NS) Fertilization rate = 64.9 vs. 63.1% (NS) No of fresh embryos replaced/cycle = 2.9 ± 0.8 vs. 2.8± 1.2 (NS) No of cycles with cryopreserved embryos: 07 vs. 17 with 5.1± 2.8 vs. 4.5 ± 2.6 cryopreserved embryos / cycle(NS). Pregnancy rate /cycle = 33.3% vs. 27.6% (NS) Pregnancy rate/transferred cycle = 34.8% vs. 28.2% (NS) Implantation rate = 13.4 vs. 17.5% (NS) Missed abortions = 37.5 vs. 41.7% (NS) Deliveries 05 vs. 13 vs. Live births 06 vs. 16 Multiple pregnancies: 01 vs. 03 One ovarian hyperstimulation syndrome occurred during COH and one severe tuberculous meningo-encephalitis followed a miscarriage in TB group; no complications in NTB group. The success rate of IVF-ET in tuberculous tubal factor infertility with a normal cavity is equal in terms of pregnancies to non tuberculous tubal factor infertility. Nevertheless the occurrence of tuberculous meningo-encephalitis is rare but a matter of concern as well.

The Evaluation of Withholding Gonadotropins (Coasting) Effects on the Outcome of In-Vitro Fertilization Cycles

Ovarian hyper stimulation syndrome (OHSS) is a rare life threatening complication of controlled ovarian stimulation for in vitro fertilization (IVF). To reduce this risk several approaches have been used. Withholding gonadotropin administration or coasting is one of the most effective and popular methods used to prevent OHSS. However the effect of coasting on the number and quality of oocyte and embryo is still controversial. In addition, the duration of coasting seems to be a prognostic factor for the outcome of IVF. The purpose of this study was to evaluate the coasting effects on the cycle outcome in patients undergoing in vitro fertilization Retrospective study Sixty-seven patients undergoing coasting were evaluated in Royan research center between May 2002 and June 2003.The study was approved by our Institutional Review Board and University of Jahad Ethics committee. After signing informed consent forms, all patients underwent standard long protocol with GnRH analogue and HMG and then in vitro fertilization and embryo transfer (IVF-ET). Coasting was considered when estradiol level was more than 3000 pg/ml and the number of follicle >10 in each ovary. HCG was administered whenever estradiol reached ≤ 3000 pg/ml and then IVF-ET program was carried out. According to coasting period, patients were divided in two groups: (coasting period ≤ 3 days and coasting period > 3 days). Statistical comparisons were performed using student t test and Fisher exact test. P value <0.05 was considered as significant level. There were no significant differences between two groups in mean age, BMI, percent of PCOS (poly cystic ovarian syndrome) patients, number of HMG ampoules and stimulation duration. A total number of retrieved oocytes decreased significantly in patients with more than 3 days of coasting(6.2 ± 4.2 vs. 9.5±5.3)(P value=0.04).Also the number of high quality oocytes decreased in this group; however they did not reach to significant levels (5.1 ±.2.9 vs. 7.6 ± 4.7) (P value = 0.06) There were no significant differences between two groups in fertilization and pregnancy rate. None of patients developed severe OHSS. This study reveals that coasting effectively prevents OHSS however long coasting period (>3 days) has negative effect on the number of oocytes, although the fertilization and pregnancy rates do not be affected. Prospective randomized study comparing coasting with other procedures is recommended.

Follicle stimulating hormone as a predictor of ovarian response in women undergoing controlled ovarian hyperstimulation for IVF

Objective: To evaluate the effect of basal follicle stimulating hormone (FHS) level on ovarian response in women undergoing controlled ovarian hyperstimulation for in vitro fertilization. Methods: A descriptive and analytic study of 212 cycles of IVF chosen from about 2200 files of women treated at Royan Institute, Tehran, Iran, from 1991 to 1999. Treatment was started with intranasal or subcutaneous buserlin (0.5 cm 3), on day 21 (long protocol). On day 2 of the next cycle, stimulation with human menopausal gonadotropin (hMG) was initiated. When the number and size of follicles were suitable, human chorionic gonadotropin (hCG) was given intramuscularly for ovulation induction, followed by oocyte retrieval 36 to 40 h later. Embryos were transferred about 48 to 72 h after oocyte retrieval. The women were assigned to 2 groups on the basis of day 3 serum FSH levels (≥ 15 IU/mL, group 1 and < 15 IU/mL, group 2). Results: There were statistically significant differences between the 2 groups in number of follicles, number of oocytes retrieved and embryos transferred (lower in group 1), and level of serum luteinizing hormone and number of canceled cycles (higher in group 1). There were no statistical differences in number of ampoules of hMG used or age of patients. Conclusion: Day-3 serum FSH level was a predictor of ovarian response and IVF outcome in this study.

Relationships between pregnancy rates following in vitro fertilization or intracytoplasmic sperm injection and endometrial thickness and pattern

Objective: To investigate the role of endometrial thickness and pattern on the day of human chorionic gonadotropin (hCG) administration on in vitro fertilization (IVF)/intracytoplasmic injection (ICSI) outcome. Study design: A total of 150 infertile women undergoing embryo transfer after IVF/ICSI cycles were studied in a prospective survey. Sonographic features of the endometrium (thickness and pattern) on the day of hCG administration, hormonal profile (progesterone, estradiol, FSH, LH) and various other variables (maternal age, causes and duration of infertility, duration of treatment, number of human menopausal gonadotropin (hMG) ampoules administered, and number of oocytes retrieved) were evaluated. These variables in pregnant and nonpregnant patients were compared. Results: There was no difference between pregnant and nonpregnant patients in mean endometrium thickness (10.1 ± 1 versus 10.2 ± 2, p = 0.79). Pregnancies occurred only in patients with an endometrial thickness of 9–12 mm ( p = 0.036). Duration of treatment, number of hMG ampoules administered, number of oocytes retrieved, estradiol concentration, and estradiol/progesterone ratio on the day of hCG differed significantly between pregnant and nonpregnant patients. There was no correlation between endometrial pattern and pregnancy rate. The receiver-operating characteristic (ROC) curve and multiple logistic regression showed no significant effect of endometrial thickness in the outcome of IVF/ICSI. Conclusion: The sonographic features of the endometrium (thickness and pattern) on the day of hCG administration did not differ between pregnant and nonpregnant patients. The pregnancy rate declined beyond two limits of endometrial thickness.

186 COMPARISON OF IVF AND ICSI TREATMENTS ON THE FERTILIZATION, EMBRYO CLEAVAGE, EMBRYO TRANSFER, PREGNANCY, AND EMBRYO IMPLANTATION RATES IN IMMUNOLOGICALLY INFERTILE PATIENTS

The objective of the present work was to study the response to in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) techniques in regard to fertilization, embryo cleavage, embryo transfer (ET), pregnancy, and embryo implantation rates using semen from immunologically infertile men. Ninety-four men with antisperm antibodies (ASA) detected in their semen and serum by slide agglutination and tray microagglutination tests were involved in IVF (IVF group) or ICSI (ICSI group) treatment. All male patients underwent sperm penetration assay (SPA) using zona-free hamster oocytes. Men with positive SPA were admitted to the IVF protocol (n = 46) and men with negative SPA were involved in the ICSI protocol (n = 48). The female patients had normal ovulatory cycles and normal reproductive hormone concentrations (FSH, LH, prolactin, estradiol and progesterone). They received human menopausal gonadotropin (hMG) and human chorionic gonadotropin (hCG) for the induction of ovulation. Follicular growth was monitored by serial vaginal sonography and measurement of estradiol concentrations. Sperm viability was assayed by a hypo-osmotic swelling test (HOST) prior to oocyte insemination. Student t-test and Chi-Square test were used for statistical analysis of the data. The clinical data of the female patients (including age, body mass index (kg/m2), infertility duration, total number of hMG ampoules, estradiol concentration on cycle Day 3 and at day of hCG injection, and endometerial thickness) in the IVF and ICSI groups were not significantly different between the groups (P &gt; 0.05). The oocyte recovery rate per patient was 6.34 (292/46) in the IVF group and 6.87 (330/48) in the ICSI group. The fertilization and embryo cleavage rates were similar (P &gt; 0.05) in the IVF and ICSI groups (61.86% (133/215) vs. 56.50% (139/246) and 78.95% (105/133) vs. 72.66% (101/139), respectively). The percentage of embryos of transferable quality (ET rate) and the number of transferred embryos per patient were significantly higher (P &lt; 0.05) in the IVF group compared to the ICSI group (73.33% (77/105) vs. 58.42% (59/101) and 1.67 vs. 1.22, respectively). The pregnancy rate per patient and embryo implantation rate were similar (P &gt; 0.05) in both IVF and ICSI groups (28.26% vs. 25% and 21.74% vs. 18.75%, respectively). It was concluded from the results of the present study that the higher ET rate and the number of the transferred embryos per patient in the IVF group may be due to the superior quality of IVF sperm compared to ICSI sperm. Both IVF and ICSI embryos showed no significant differences in their pregnancy and embryo implantation rates; this may indicate that both types of embryos are viable and have similar pregnancy and embryo implantation potentials following ET, provided that the female patients have normal ovulatory cycles and normal concentrations of reproductive hormones. SPA and HOST were found to be useful tests for the selection of spermatozoa in ASA positive male patients for involvement in IVF or ICSI procedures.

A double-blind, randomized, placebo-controlled study to assess the efficacy of ketoconazole for reducing the risk of ovarian hyperstimulation syndrome

Objective To evaluate the role of ketoconazole in prevention of ovarian hyperstimulation syndrome (OHSS) in women with the polycystic ovary syndrome (PCOS) undergoing ovarian stimulation with gonadotropins. Design Prospective, randomized, double-blind, placebo-controlled study. Setting University hospitals. Patient(s) One hundred nine women with PCOS who were referred for treatment with gonadotropins. Intervention(s) Fifty patients were randomly assigned to receive two ampoules of hMG beginning on day 2 or 3 of the cycle and ketoconazole (50 mg every 48 hours) starting on the first day of hMG treatment. Fifty-one patients received the same amount of hMG plus one tablet of placebo every 48 hours. Main outcome measure(s) Follicular development, E 2 level, and pregnancy rate. Result(s) The total number of hMG ampoules and duration of treatment to attain ovarian stimulation were higher among ketoconazole recipients. The serum E 2 level and number of patients with dominant follicles on day 9 of the cycle were greater in placebo recipients. Serum E 2 level and total number of follicles at the time of hCG administration did not differ between the two groups. The cancellation rate and OHSS rate were similar in the two groups. Conclusion(s) Ketoconazole does not prevent OHSS in patients with PCOS who are undergoing ovarian stimulation. It may reduce the rate of folliculogenesis and steroidogenesis.

Minimal stimulation protocol for use with intrauterine insemination in the treatment of infertility.

To determine whether minimal stimulation with clomiphene and one injection of 150 IU of human menopausal gonadotrophin (hMG) provides pregnancy rates comparable with those in a conventional full hMG stimulation protocol for infertile patients undergoing intrauterine insemination (IUI). A prospective study was carried out at the Infertility Clinic of a teaching institute and tertiary care referral center in Chandigarh, India. Two hundred couples with either unexplained infertility or ovulatory dysfunction cases who ovulated with clomiphene citrate (CC) but failed to conceive were offered ovarian stimulation with CC and hMG along with IUI for 420 cycles. Pregnancy rate, medication and monitoring cost were compared between minimal and conventional stimulation protocols. There was no difference in the couples of the two stimulation protocols regarding their age, duration and type of infertility as well as cause of infertility. Number of ampoules of hMG and monitoring costs were significantly higher in the full hMG stimulation cases whereas pregnancy rate was comparable in both protocols. Minimal stimulation appears to be an effective protocol in cases of unexplained infertility undergoing intrauterine insemination. Reduced cost and minimal monitoring is appealing to patients and the clinician.

Follicular fluid and serum concentrations of myo-inositol in patients undergoing IVF: relationship with oocyte quality

The follicular microenvironment is an important determinant of oocyte development. The aim of this study was to examine whether the myo-inositol (MI) content in human follicular fluid (FF) was associated with better oocyte quality. A total of 53 patients treated with IVF was recruited to a prospective observational study. FF and serum samples collected were divided into two groups: group A consisted of FF associated with matured and fertilized oocytes, whilst group B was from follicles with immature and unfertilized oocytes. Patient's age, total ampoules of HMG used, days of stimulation, basal levels of FSH, estradiol (E(2)) levels on the day of HCG, and serum MI content were not significantly different between the two groups. FF volume and its MI content were significantly higher in group A compared with group B (P < 0.05). The levels of MI in FF were positively correlated with the amount of E(2) in their corresponding FF samples and also correlated with embryo quality. We propose that higher concentrations of MI and E(2) in human FF appear to play a role in follicular maturity and provide a marker of good quality oocytes.

Increasing the gonadotrophin dose in the course of an in vitro fertilization cycle does not rectify an initial poor response

Objective: To evaluate the value of increasing the gonadotrophin dose after 5 days of controlled ovarian stimulation in IVF patients who show an initial poor response to stimulation. Subjects and methods: We identified all IVF cycles between January 1992 and March 1996 in which ovarian response after 5 days of controlled ovarian hyperstimulation (COH) with 225–300 IU per day of human menopausal gonadotrophins (hMG; Metrodin or Pergonal) was monitored by measurement of serum estradiol concentrations ( n=596 patients). According to estradiol concentration, the daily dose of hMG was doubled or increased to 450 IU in 193 patients (group A) or maintained the same in 403 patients (group B). Further cycle monitoring was achieved using serial ultrasound and serum estradiol measurements. Results: The two groups were age-matched. Group A patients experienced a higher cancellation rate despite having a higher mean number of hMG ampoules (59.5 versus 36.2) and a longer duration of stimulation (12.2 versus 10.8 days). They achieved lower levels of serum estradiol on days 9 and 10 of stimulation, produced a lower mean number of oocytes per retrieval (5.8 versus 8.9) and had a lower clinical pregnancy rate per cycle (8.3 versus 23.4%) compared to group B. All differences were statistically significant. Conclusion: The poor outcome of cycles with initial low response to COH appears not to be averted by doubling or increasing the hMG dose after 5 days of stimulation.