GnRH Agonist Protocol Research Articles

Ovarian response prediction in GnRH antagonist treatment for IVF using anti-Müllerian hormone.

What is the clinical value of anti-Müllerian hormone (AMH) for the prediction of high or low ovarian response in controlled ovarian stimulation for IVF using GnRH antagonist treatment? AMH as a single test has substantial accuracy for ovarian response prediction in GnRH antagonist treatment for IVF, with a higher accuracy for predicting a high response than for low response. The role of AMH and other patient characteristics in ovarian response prediction has been studied extensively in long GnRH agonist protocols; however, little information is available regarding the clinical value in GnRH antagonists. This is an observational (retrospective) substudy as part of an ongoing cohort study. A total of 487 patients scheduled for IVF/ICSI between 2006 and 2011 were included in the study. Patients with a regular cycle who underwent their first IVF/ICSI cycle with GnRH antagonist treatment while receiving a starting dose of 150 or 225 IU recombinant FSH were included in the study. Patients were divided into three subgroups according to the following ovarian response categories: high (>15 oocytes or cycle cancellation), normal (4-15 oocytes) and low (<4 oocytes or cycle cancellation). Serum samples collected prior to IVF treatment were used to determine serum AMH levels. According to the predefined ovarian response categories, 58 patients were classified as high, 326 as normal and 101 as low responders, and the ongoing pregnancy rates did not differ among groups (19.0, 22.1 and 16.8%, respectively, P = 0.9). For the prediction of high response, AMH had an area under the receiver-operating characteristic curve (AUC) of 0.87. Both female age and BMI had lower accuracy (AUC 0.66 and 0.58, respectively). For low response prediction, again AMH had a better accuracy (AUC 0.79) than female age and BMI (AUC 0.59 and 0.56, respectively). In a multivariate model, including the factors age, AMH, BMI, smoking, type and duration of subfertility, only BMI added some predictive value to AMH for both high and low response prediction. Clinical test characteristics demonstrated that using a specificity of ∼90%, the detection rate of AMH for high and low response, corresponding with a test cut-off of 4.5 and 0.8 µg/l, was ∼60 and ∼45%, respectively. The impact of the antral follicle count (AFC) on ovarian response prediction in GnRH antagonists was not assessed; however, previously studies demonstrated that for GnRH antagonists, AMH has a better accuracy than AFC. The current study demonstrates that AMH is an adequate predictor for both high and low response in GnRH antagonist cycles, showing a similar accuracy to GnRH agonists, as reported previously. The optimization and individualization of GnRH antagonist protocols may be improved by using an AMH-tailored approach. This study was funded by the Academic Institutional Resources of the Department of Reproductive Medicine of the UMC Utrecht. O.H., M.J.C.E, E.W.G.L and H.L.T. have nothing to declare. N.S.M. has received fees and/or grant support from the following companies (in alphabetic order): Anecova, Ferring, Informa, Merck Serono and MSD. B.C.J.M.F. has received fees and/or grant support from the following companies (in alphabetic order); Childhealth, CVON, Ferring, Ova-Science, PregLem, Roche and Watson laboratories. F.J.B. has received fees and/or grant support from the following companies (in alphabetic order); Merck Serono and MSD. www.clinicaltrials.gov, Protocol ID 13-109.

GnRH agonist plus vaginal progesterone for luteal phase support in ICSI cycles: a randomized study

In this prospective randomized study, the effect of daily gonadotrophin-releasing hormone agonist (GnRHa) in the luteal phase on IVF and intracytoplasmic sperm injection (ICSI) outcomes was assessed. Women (n = 446) were counselled for IVF–ICSI, and randomized on the day of embryo transfer to group 1 (daily 0.1 mg subcutaneous GnRHa until day of beta-HCG) (n = 224) and group 2 (stopped GnRHa on day of HCG injection) (n = 222). Both groups received daily vaginal progesterone suppositories. Primary outcome was clinical pregnancy rate. Secondary outcome was ongoing pregnancy rate beyond 20 weeks. Mean age, oestradiol on day of HCG, number of oocytes retrieved, number of embryos transferred, and clinical and ongoing pregnancy rates were 28.9 ± 4.5 years, 2401 ± 746 pg/mL; 13.5 ± 6.0 oocytes; 2.6 ± 0.6 embryos, and 36.2% and 30.4% consecutively in group 1 compared with 29.7 ± 4.7 years, 2483 ± 867 pg/mL, 13.7 ± 5.5 oocytes, 2.7 ± 0.6 embryos, 30.6% pregnancy rate, and 25.7% ongoing pregnancy rate in group 2. No significant difference was found between the groups. Subcutaneous GnRHa during the luteal phase of long GnRHa protocol cycles does not increase clinical or ongoing pregnancy rates after IVF–ICSI.

Is the Flexible GnRH Antagonist Protocol Better Suited for Fresh eSET Cycles?

ObjectiveThis study was performed to evaluate the efficacy of the flexible GnRH antagonist protocol in comparison with the long GnRH agonist protocol in elective single embryo transfer (eSET) practice. It was conducted in a publicly funded in vitro fertilization program. MethodsWe performed a prospective cohort analysis of data from a private infertility clinic from August 2010 to August 2011. Three hundred fourteen women with normal ovarian reserve and undergoing fresh eSET cycles were included. Sixty-four women underwent follicular stimulation using a flexible GnRH antagonist protocol, and 250 underwent stimulation with a standard long mid-luteal GnRH agonist protocol. ResultsImplantation rates (35.9% in the GnRH antagonist group and 29.6% in the GnRH agonist group, P=0.5) and ongoing pregnancy rates (32.8% in the GnRH antagonist group and 28.8% in the GnRH agonist group, P=0.5) were equivalent in both groups. The duration of stimulation (9.8±2days vs. 10.7±1.8days, P<0.001) and total FSH dose required (2044 vs. 2775IU, P<0.001) were lower in the GnRH antagonist group than in the GnRH agonist group. The number of mature oocytes (6.0 vs. 10.0, P<0. 001) and number of embryos (5.0 vs. 7.0, P<0.001) were also lower in GnRH antagonist group. However, the number of embryos cryopreserved was similar in both groups (median 2.0, P=0.3). ConclusionIn women undergoing in vitro fertilization, the flexible GnRH antagonist protocol yields implantation and ongoing pregnancy rates that are similar to the long GnRH agonist protocol, and requires lower doses of gonadotropins and a shorter duration of treatment. The flexible GnRH antagonist protocol appears to be the protocol of choice for an eSET IVF program.

Luteal-long GnRH agonist versus flexible-multidose GnRH antagonist protocols for overweight and obese patients who underwent ICSI

A total of 413 consecutive infertile patients (572 cycles) with a body mass index (BMI) of ≥ 25 kg/m2 were enrolled into the study. The luteal-long GnRH agonist group (Group I) constituted 211 patients (300 cycles) and the flexible-multidose GnRH antagonist group (Group II) constituted 202 patients (272 cycles). The duration of stimulation (d) (10.1 ± 2.5 vs 9.2 ± 2.0; p < 0.01); the total dose of gonadotrophin used (IU) (3,099.4 ± 2,885.0 vs 2,684.0 ± 1,046.4; p < 0.05) and the E2 level on the day of hCG (pg/ml) (2,375.8 ± 1,554.6 vs 1,905.6 ± 1,598.8; p < 0.01) were significantly lower in Group II when compared with Group I. However, the ongoing pregnancy per embryo transfer (37.0% vs 25.7%; p < 0.05) and the implantation rate (25.7% vs 15.6%; p < 0.01) were significantly lower in Group II when compared with Group I. In conclusion, we noted that the luteal-long GnRH agonist protocol produced higher implantation rates and higher clinical-ongoing pregnancy rates in overweight and obese patients when compared with the flexible-multidose GnRH antagonist protocol.

First report of a successful singleton live birth in a female with 17-hydroxylase deficiency through IVF frozen-thawed embryo transfer after adequate endometrial preparation

To report a singleton live birth in a female patient with congenital adrenal hyperplasia (CAH) due to 17-hydroxylase deficiency. Case report. A 29 years old female with CAH due to 17-hydroxylase deficiency presented with infertility. CAH due to 17-hydroxylase deficiency in 46,XX patients is characterized by low serum levels of estradiol (E2) and high levels of progesterone (P). Therefore it is associated with ovulatory dysfunction, ovarian cysts and inadequate endometrial development for embryo implantation. No other infertility factors could be identified. IVF was recommended, considering the complexity of the disorder. Ovulation induction (OI) was achieved with a long GnRH agonist protocol and recombinant FSH (rFSH). All embryos were electively cryopreserved (vitrification) after 5 days of development. Goserelin acetate was administered after menstruation to suppress ovarian synthesis of P. The patient also received 0.5 mg/day of dexamethasone acetate to reduce adrenal synthesis of P. Once P was < 1ng/mL endometrial preparation (EP) with estradiol valerate (6mg/day orally) was initiated. OI was accomplished with 1237,5 IU of rFSH over 11 days. At the end of OI, P was 13 ng/mL and E2< 13pg/mL. Four mature oocytes were retrieved and fertilized (ICSI) by a fresh semen sample. On the fifth day of embryo culture, two morulae were cryopreserved. Goserelin acetate (10,8mg) was administered subcutaneously one month after oocyte retrieval. Three months later, when P< 1ng/mL, EP was started. When endometrial thickness reached 8 mm (18th day of EP), 200mg of micronized progesterone were administered vaginally t.i.d. Five days later, embryos were thawed and transferred into the uterus. β hCG tested positive 10 days later. A singleton pregnancy was confirmed with transvaginal ultrasound at the 6th week of gestational age. Hormonal support (estradiol + progesterone) was maintained until 8 weeks of GA. A live birth occurred at 30 weeks of GA due to fetal distress (true umbilical knot). The neonate was discharged in good conditions after 30 days of neonatal ICU. A live birth was achieved through IVF, cryopreservation of embryos and frozen thawed embryo transfer after the reduction of P synthesis in a patient with 17-hydroxylase deficiency.

Factors predicting oocyte maturation in high responders undergoing controlled ovarian hyperstimulation

Oocyte donors and women electing fertility preservation are at increased risk of developing ovarian hyperstimulation syndrome (OHSS). Different strategies are used to lower the risk, such as decreasing the hCG dose or using gonadotropin releasing hormone agonist (GnRHa) as an alternative to hCG. However, trigger failures can occur when using GnRHa alone. Alternatively, adding low dose hCG to GnRHa may allow a decreased incidence of OHSS while avoiding trigger failures. Retrospective chart review of oocyte donation and fertility preservation cycles using GnRHa and long luteal protocols between 01/01/10 and 02/02/14. 364 total IVF/ICSI cycles were analyzed. Oocyte maturity was induced by either GnRHa, hCG, or GnRHa plus 1500IU hCG. Correlation of post trigger LH and hCG levels to maturation parameters were assessed in 199 cycles. Spearman’s correlation assessed correlation between post-GnRHa trigger LH with proportion of total and mature oocytes retrieved as well as fertilization. 1-way ANOVA was used to compare oocyte maturation between each different trigger. All 3 failed triggers were with GnRHa only. No OHSS developed after GnRHa plus 1500IU hCG. No difference was noted in proportion of metaphase II (MII) oocytes to mature size follicles measured on day trigger, MII oocytes to total oocytes retrieved, or the number of 2 pronuclei (2PN) to total oocytes retrieved between those that were triggered with either hCG, GnRHa, or GnRHa plus 1500IU hCG. No difference was appreciated in the same proportions when comparing hCG trigger dose of 10000, 5000, and 3300 IU. There was a significant negative correlation of the LH level post-GnRHa plus hCG trigger to the proportion of 2PN and oocytes retrieved (p = 0.046) but not with GnRHa alone. No other significant correlations were found between parameters of oocyte maturity and post trigger LH.Tabled 1Characteristics based on triggerVariableshCG onlyGnRHa onlyGnRHa + hCGP valueAge24.9±2.826.7±4.226.3±4.10.079AFC24.6±9.928.9±9.829.1±9.50.004Follicles >13mm18.7±5.726.1±7.924.2±6.4<0.001# MII19.9±8.825.8±12.024.8±12.50.063Maturity(MII/ follicles >13mm)1.07±0.391.03±0.351.02±0.370.831Fertilization (2PN/total oocytes retrieved)0.67±0.160.63±0.160.65±0.190.453Mean ± STD Open table in a new tab Mean ± STD Adding low dose hCG to a GnRHa trigger may allow a decrease in OHSS incidence, and appears to not compromise oocyte maturity while avoiding failed oocyte maturation. Using this alternative form of trigger appears to be most optimal for donor and fertility preservation cycles that are at very high risk of developing OHSS.

The effect of LH supplementation following GnRH antagonist administration in advanced reproductive ageing women undergoing IVT-ET: a prospective randomized controlled study

Although the fundamental significance of both LH and FSH for adequate ovarian folliculogenesis and steroidgenesis has been extensively discussed, the clinical implication of recombinant (r) LH for ovarian stimulation remains to be elucidated. It has been reported that there is no increase in pregnancy rate following rLH supplementation to the long GnRH agonist and rFSH protocol in the general infertile women undergoing IVF-ET. However, pooled pregnancy estimates of clinical trials including only low responder women showed significant increase in pregnancy rate, in favor of co-administrating rLH.

The addition of gonadotrophin releasing hormone agonist to routine luteal phase support in intracytoplasmic sperm injection and embryo transfer cycles: a randomized clinical trial

ObjectivesTo determine the effects of addition of different dosages of gonadotrophin releasing hormone agonist (GnRH-a) to routine luteal phase support (LPS) on implantation and pregnancy rates. Study designThree hundred infertile couples who were treated by intracytoplasmic sperm injection and embryo transfer (ICSI-ET) following controlled ovarian stimulation (COS) with long luteal GnRH agonist protocol were enrolled. All women received 600mg/day vaginal micronized progesterone plus 4mg 17β estradiol for LPS starting from the day of oocyte retrieval. Patients (n=300) were randomized into three treatment groups. Group A (n=100) received leuprolide acetate 1mg s.c. injection 3 days after ET in addition to routine LPS. Group B (n=100) received two sequential doses of leuprolide acetate 1mg s.c. injections 3 and 6 days after ET in addition to routine LPS. Control group (n=100) received only the routine LPS. ResultsA total of 279 patients completed the study. The groups were comparable in terms of baseline demographic parameters including age, duration of infertility and day 3 levels of FSH and estradiol. The cycle parameters of the groups were also comparable regarding the E2 level on day of hCG, number of retrieved oocytes, number of day 3 embryos, number of embryos transferred, and endometrial thickness on both days of OPU and ET. The implantation rates were similar in between the Groups A, B, and control group (20.7% and 25.8% vs. 13.3%, respectively; P=.099). The clinical pregnancy rates and miscarriage rates were similar in between the groups. The ongoing pregnancy rates were 27.4% in control group, 36% in Group A and 42.9% in Group B (P=.093). The OHSS rates were comparable in between the groups. The multiple pregnancy rates were significantly higher in Groups A and B than in control group (12% and 17.9% vs. 4.2%, respectively; P=.014). ConclusionsThe implantation, clinical pregnancy and ongoing pregnancy and multiple pregnancy rates seem to be increased with the addition of GnRH-a to routine luteal phase support.

Microdose flare-up vs. flexible-multidose GnRH antagonist protocols for poor responder patients who underwent ICSI

Purpose: To compare the performance of microdose flare-up (MF) and flexible-multidose gonadotropin-releasing hormone (GnRH) antagonist protocols in poor responder patients who underwent intracytoplasmic sperm injection (ICSI). Materials and Methods: One hundred and 12 consecutive patients (217 cycles) suspected to have poor ovarian response were enrolled. Group 1 (MF GnRH agonist group) constituted 64 patients (135 cycles) who underwent MF GnRH agonist protocol. Group 2 (flexible-multidose GnRH antagonist group) constituted 48 patients (82 cycles) who underwent flexible-multidose GnRH antagonist protocol. Results: The duration of stimulation (d) (11.5 &#x00B1; 2.1 vs. 10.4 &#x00B1; 2.7, p p p p p p p Conclusions: Although the flexible-multidose GnRH antagonist protocol produced better oocyte and embryo parameters, the clinical pregnancy rate and the implantation rates were comparable between the flexible-multidose GnRH antagonist and MF protocols in poor responder patients.

GnRH agonist and GnRH antagonist protocols: comparison of outcomes among good-prognosis patients using national surveillance data

Implantation and live birth rates resulting from IVF cycles using gonadotropin-releasing hormone (GnRH) agonist and (GnRH) antagonist IVF protocols were compared among good-prognosis patients using the Centers for Disease Control and Prevention's National Assisted Reproductive Technology Surveillance System 2009–2010 data (n = 203,302 fresh, autologous cycles). Bivariable and multivariable analyses were conducted between cycles to compare outcomes. Cycles were restricted as follows: age younger than 35 years, maximum FSH less than 10 mIU/mL, first assisted reproduction technology cycle and FSH dose less than 3601 IU. A subgroup analysis including only elective single embryo transfer was also carried out. Among good-prognosis patients, the GnRH-agonist protocol was associated with a lower risk of cancellation before retrieval (4.3 versus 5.2%; P < 0.05) or transfer (5.5 versus 6.8%; P < 0.05), and a higher live birth rate per transfer (adjusted odds ratio [OR] 1.13, confidence interval [CI] 1.03 to 1.25) than the GnRH-antagonist group. Among the elective single embryo transfer group, the GnRH-agonist protocol was associated with a higher implantation rate (adjusted odds ratio [OR] 1.36, CI 1.08 to 1.73) and a higher live birth rate (adjusted OR 1.33, CI 1.07 to 1.66) compared with the GnRH-antagonist protocol. The GnRH-antagonist group had lower rates of ovarian hyperstimulation syndrome. Among good-prognosis patients, agonist protocols decreased cancellation risk and increased odds of implantation and live birth. Antagonist protocols may confer decreased risk of hyperstimulation.

Prognostic models for high and low ovarian responses in controlled ovarian stimulation using a GnRH antagonist protocol.

STUDY QUESTIONCan predictors of low and high ovarian responses be identified in patients undergoing controlled ovarian stimulation (COS) in a GnRH antagonist protocol?SUMMARY ANSWERCommon prognostic factors for high and low ovarian responses were female age, antral follicle count (AFC) and basal serum FSH and LH.WHAT IS KNOWN ALREADYPredictors of ovarian response have been identified in GnRH agonist protocols. With the introduction of GnRH antagonists to prevent premature LH rises during COS, and the gradual shift in use of long GnRH agonist to short GnRH antagonist protocols, there is a need for data on the predictability of ovarian response in GnRH antagonist cycles.STUDY DESIGN, SIZE, DURATIONA retrospective analysis of data from the Engage trial and validation with the Xpect trial. Prognostic models were constructed for high (>18 oocytes retrieved) and low (<6 oocytes retrieved) ovarian response. Model building was based on the recombinant FSH (rFSH) arm (n = 747) of the Engage trial. Multivariable logistic regression models were constructed in a stepwise fashion (P < 0.15 for entry). Validation based on calibration was performed in patients with equivalent treatment (n = 199) in the Xpect trial.PARTICIPANTS/MATERIALS, SETTING, METHODSInfertile women with an indication for COS prior to IVF. The Engage and Xpect trials included patients of similar ethnic origins from North America and Europe who had regular menstrual cycles. The main causes of infertility were male factor, tubal factor and endometriosis.MAIN RESULTS AND THE ROLE OF CHANCEIn the Engage trial, 18.3% of patients had a high and 12.7% had a low ovarian response. Age, AFC, serum FSH and serum LH at stimulation Day 1 were prognostic for both high and low ovarian responses. Higher AFC and LH were associated with an increased chance of high ovarian response. Older age and higher FSH correlated with an increased chance of low ovarian response. Region (North America/Europe) and BMI were prognostic for high ovarian response, and serum estradiol at stimulation Day 1 was associated with low ovarian response. The area under the receiver operating characteristic (ROC) curve (AUC) for the model for a high ovarian response was 0.82. Sensitivity and specificity were 0.82 and 0.73; positive and negative predictive values were 0.40 and 0.95, respectively. The AUC for the model for a low ovarian response was 0.80. Sensitivity and specificity were 0.77 and 0.73, respectively; positive and negative predictive values were 0.29 and 0.96, respectively. In Xpect, 19.1% of patients were high ovarian responders and 16.1% were low ovarian responders. The slope of the calibration line was 0.81 and 1.35 for high and low ovarian responses, respectively, both not statistically different from 1.0. In summary, common prognostic factors for high and low ovarian responses were female age, AFC and basal serum FSH and LH. Simple multivariable models are presented that are able to predict both a too low or too high ovarian response in patients treated with a GnRH antagonist protocol and daily rFSH.LIMITATIONS, REASONS FOR CAUTIONAnti-Müllerian hormone was not included in the prediction modelling.WIDER IMPLICATIONS OF THE FINDINGSThe findings will help with the identification of patients at risk of a too high or too low ovarian response and individualization of COS treatment.STUDY FUNDING/COMPETING INTERESTSFinancial support for this study and the editorial work was provided by Merck, Sharp & Dohme Corp. (MSD), a subsidiary of Merck & Co. Inc., Whitehouse Station, NJ, USA. F.J.B. received a grant from CVZ to his institution; P.J.M.V. and H.W. are employees of MSD, and B.M.J.L.M. was an employee of MSD at the time of development of this manuscript.TRIAL REGISTRATION NUMBERSNCT 00696800 and NCT00778999.

Does prolonged pituitary down-regulation with gonadotropin-releasing hormone agonist improve the live-birth rate in in vitro fertilization treatment?

To evaluate the effects of a prolonged duration of gonadotropin-releasing hormone agonist (GnRH-a) in pituitary down-regulation for controlled ovarian hyperstimulation (COH) on the live-birth rate in nonendometriotic women undergoing invitro fertilization and embryo transfer (IVF-ET). Retrospective cohort study. University-affiliated hospital. Normogonadotropic women undergoing IVF. Three hundred seventy-eight patients receiving a prolonged pituitary down-regulation with GnRH-a before ovarian stimulation and 422 patients receiving a GnRH-a long protocol. Live-birth rate per fresh ET. In comparison with the long protocol, the prolonged down-regulation protocol required a higher total dose of gonadotropins. A lower serum luteinizing hormone (LH) level on the starting day of gonadotropin and the day of human chorionic gonadotropin (hCG) and a fewer number of oocytes and embryos were observed in the prolonged down-regulation protocol. However, the duration of stimulation and number of high-quality embryos were comparable between the two groups. A statistically significantly higher implantation rate (50.27% vs. 39.69%), clinical pregnancy rate (64.02% vs. 56.87%) and live-birth rate per fresh transfer cycle (55.56% vs. 45.73%) were observed in the prolonged protocol. Prolonged down-regulation in a GnRH-a protocol might increase the live-birth rates in normogonadotropic women.

The serum level of C-reactive protein in patients undergoing GnRH agonist protocols for in vitro fertilization cycle

Background: The synchronization of the uterus and mature eggs at the molecular level is the key factor in embryo transfer, and the regulation of synchronization depends on a variety of cytokines. C-reactive protein (CRP), as the first acute phase reaction protein, is involved in the entire process of embryo transfer. The study is designed to investigate the correlation among CRP, sex hormone, controlled ovarian hyperstimulation (COH) cycle, and pregnancy outcome. Materials and Methods: Ninety-two patients who accepted in vitro fertilization (IVF) treatment cycles because of tubal factor were included in the study. Seventy treated cases were included to complete final analysis with the full set of results. Respectively on the second day of the menstruation (Day-2) in gonadotropin-releasing hormone agonist (GnRH-a) short program treatment, on the morning in human chorionic gonadotropin (hCG) treatment (Day-hCG) and the embryo transplant day (Day-ET), plasma CRP level was tested by enzyme-linked immunosorbent assay (ELISA). The correlativity among CRP level, sex hormone, COH, and pregnancy outcome was analyzed by statistical methods. Results: In the short program GnRH-a of 70 cases, there was no relationship between serum CRP level and the infertility age, gonadotropin (Gn) dosage, number of oocytes retrieved, the number of normal fertilization, and sex hormone. In the short program of GnRH-a, the change of serum CRP levels in Day-2, Day-hCG, Day-ET: serum CRP in Day-2 Conclusion: CRP as a sensitive inflammatory marker, CRP ratio of Day-ET/ Day-hCG could be a predictor of treatment outcome by ROC curve analysis in COH program.

The rate of high ovarian response in women identified at risk by a high serum AMH level is influenced by the type of gonadotropin

The aim was to compare ovarian response and clinical outcome of potential high-responders after stimulation with highly purified menotropin (HP-hMG) or recombinant follicle-stimulating hormone (rFSH) for in vitro fertilisation/intracytoplasmic sperm injection. Retrospective analysis was performed on data collected in two randomized controlled trials, one conducted following a long GnRH agonist protocol and the other with an antagonist protocol. Potential high-responders (n = 155 and n = 188 in the agonist and antagonist protocol, respectively) were defined as having an initial anti-Müllerian hormone (AMH) value >75th percentile (5.2 ng/ml). In both protocols, HP-hMG stimulation in women in the high AMH category was associated with a significantly lower occurrence of high response (≥15 oocytes retrieved) than rFSH stimulation; 33% versus 51% (p = 0.025) and 31% versus 49% (p = 0.015) in the long agonist and antagonist protocol, respectively. In the potential high-responder women, trends for improved live birth rate were observed with HP-hMG compared with rFSH (long agonist protocol: 33% versus 20%, p = 0.074; antagonist protocol: 34% versus 23%, p = 0.075; overall population: 34% versus 22%, p = 0.012). In conclusion, the type of gonadotropin used for ovarian stimulation influences high-response rates and potentially clinical outcome in women identified as potential high-responders.

Identification of new ovulation-related genes in humans by comparing the transcriptome of granulosa cells before and after ovulation triggering in the same controlled ovarian stimulation cycle

Which genes and molecular mechanisms are involved in the human ovulatory cascade and final oocyte maturation? Up-regulated genes in granulosa cells (GC) represented inflammation, angiogenesis, extracellular matrix, growth factors and genes previously associated with ovarian cancer, while down-regulated genes mainly represented cell cycle and proliferation. Radical changes occur in the follicle during final follicle maturation after the ovulatory trigger: these range from ensuring an optimal milieu for the oocyte in meiotic arrest to the release of a mature oocyte and remodeling into a corpus luteum. A wide range of mediators of final follicle maturation has been identified in rodents, non-human primates and cows. Prospective cohort study including 24 women undergoing ovarian stimulation with the long gonadotrophin-releasing hormone agonist protocol during 2010-2012 at Holbæk Fertility Clinic. Nine paired samples of GC and 24 paired samples of follicular fluid (FF) were obtained before and after recombinant human chorionic gonadotrophin (rhCG) administration. Nine paired (nine arrays before rhCG and nine arrays after rhCG) samples of GC mRNA were amplified and hybridized to Affymetrix Human Gene 1.0 ST GeneChip arrays, compared and bioinformatically analyzed. Eleven selected genes were validated by quantitative reverse transcriptase PCR. FF hormones were analyzed by enzyme-linked immunosorbent assay. Eleven hundred and eighty-six genes were differentially expressed (>2-fold, P<0.0001, false discovery rate <0.0012) when comparing GC isolated before and 36 h after hCG, among those were genes known to be expressed at ovulation, i.e. ADAMTS1 and HAS2. Many new ovulation-related genes were revealed, such as CD24, ANKRD22, CLDN11 and FBXO32. FF estrogen, androstenedione and anti-Müllerian hormone decreased significantly while progesterone increased, accompanied by radical changes in the expression of steroidogenic genes (CYP17A, CYP19A, HSD11B1 and HSD11B2, StAR). Genes related to inflammation, angiogenesis, extracellular matrix formation, growth factors and cancer were up-regulated while cell cycle genes were massively down-regulated. Seventy-two genes previously described in connection with ovarian cancer were among the highly regulated genes. In silico analysis for top upstream regulators of the ovulatory trigger suggested--besides LH--TNF, IGF1, PGR, AR, EGR1 (early growth response 1), ERK1/2 (extracellular signal regulated kinase 1/2) and CDKN1A (cyclin-dependent kinase inhibitor 1A) as potential mediators of the LH/hCG response. The present dataset was generated from women under hormonal stimulation. However, comparison with a macaque natural cycle whole follicle ovulation dataset revealed major overlap, supporting the idea that the ovulation-related genes found in this study are relevant in the human natural cycle. These data will serve as a research resource for genes involved in human ovulation and final oocyte maturation. Ovulation-related genes might be good candidate biomarkers of follicle and oocyte health. Further, some of the ovulation-related genes may serve as future ovarian cancer biomarkers. Grants from the Research Fund of Region Sjælland are gratefully acknowledged. None of the authors declared any conflict of interest. Not applicable.

Early Initiation of Gn RH Antagonist versus long agonist Protocols in PCOS Patients Undergoing ICSI Cycles.

AbstractPurpose: To compare the efficacy of early initiation of Gonadotrophin Releasing Hormone (GnRH) antagonist in comparison with the GnRH agonist protocol in Polycystic Ovarian Syndrome (PCOS) patients undergoing Intracytoplasmic Sperm Injection (ICSI) cycles. Materials and methods: Prospective randomized controlled trial. Seventy infertile PCOS patients under 35 years of age coming for the first trial IVF/ICSI treatment at the infertility care unit were included in the study. They were randomized to either GnRH agonist long protocol (control group A) or early initiation of GnRh antagonist (study group B) after pretreatment with OCP. Ovulation was triggered with Humman Chorionic Gonadotrophin (hCG) when at least 3 mature follicles 18 mm were detected. Results: Age, body mass index, duration of infertility, basal Follicle Stimulating Hormone (FSH), Lutinizing Hormone (LH), Estradiol (E2) at the first day of the cycle, the number of oocytes retrived, the total number of embryos, chemical, clinical pregnancy and implantation rates were comparable in both groups and there was no statistically significant difference. The stimulation period was shorter in group B than group A and number of ampoules of gonadotrophins ampoules and Serum E2 level on the day of hCG administration were significantly lower in group B than that of the group A with statistically significant differences. Moderate OHSS was documented in 4 cycles of group A but was not in any cycle of group B and this difference was statistically significant. No cases of severe OHSS were documented in both groups.Conclusions: This novel antagonist protocol may be a safe and efficient treatment for PCOS patients undergoing ICSI cycles with comparable results to the standard long GnRH agonist protocol.

Early Initiation of Gn RH Antagonist versus long agonist Protocols in PCOS Patients Undergoing ICSI Cycles

AbstractPurpose: To compare the efficacy of early initiation of Gonadotrophin Releasing Hormone (GnRH) antagonist in comparison with the GnRH agonist protocol in Polycystic Ovarian Syndrome (PCOS) patients undergoing Intracytoplasmic Sperm Injection (ICSI) cycles. Materials and methods: Prospective randomized controlled trial. Seventy infertile PCOS patients under 35 years of age coming for the first trial IVF/ICSI treatment at the infertility care unit were included in the study. They were randomized to either GnRH agonist long protocol (control group A) or early initiation of GnRh antagonist (study group B) after pretreatment with OCP. Ovulation was triggered with Humman Chorionic Gonadotrophin (hCG) when at least 3 mature follicles 18 mm were detected. Results: Age, body mass index, duration of infertility, basal Follicle Stimulating Hormone (FSH), Lutinizing Hormone (LH), Estradiol (E2) at the first day of the cycle, the number of oocytes retrived, the total number of embryos, chemical, clinical pregnancy and implantation rates were comparable in both groups and there was no statistically significant difference. The stimulation period was shorter in group B than group A and number of ampoules of gonadotrophins ampoules and Serum E2 level on the day of hCG administration were significantly lower in group B than that of the group A with statistically significant differences. Moderate OHSS was documented in 4 cycles of group A but was not in any cycle of group B and this difference was statistically significant. No cases of severe OHSS were documented in both groups.Conclusions: This novel antagonist protocol may be a safe and efficient treatment for PCOS patients undergoing ICSI cycles with comparable results to the standard long GnRH agonist protocol.

Live birth of monochorionic triamniotic triplets after in vitro fertilization and blastocyst transfer: case report and review of the literature

Monozygotic triplet pregnancies are very rare, even after in vitro fertilization (IVF). We present a case of a live birth of triplets from a monochorionic triamniotic pregnancy after blastocyst transfer. A 29-year-old woman underwent intracytoplasmic sperm injection (IVF-ICSI). Her medical history included a 4-year infertility treatment with ovarian stimulation, three cycles of intrauterine insemination, hysteroscopy and an unsuccessful attempt at IVF. During the second IVF attempt, the patient underwent ovulation simulation according to the long GnRH agonist protocol. Eleven metaphase II (MII) oocytes were injected with spermatozoa, resulting in four expanded blastocysts. In the end, two blastocysts (4AA) were transferred into the uterine cavity. Ultrasound examination performed at 7 weeks of gestation showed an ongoing triamniotic triplet pregnancy. Regular uterine contractions began at 33 weeks of gestation and a cesarean section was performed, resulting in a birth of three healthy girls, weighing 2060g (Apgar 7), 1860g (Apgar 6), 2000g (Apgar 6). After 13 days of hospitalization the infants and the mother were discharged home. The causes of monozygotic multiple gestations in spontaneous and ART pregnancies are poorly understood. They seem to occur more often after IVF. Any definitive relationship between particular stages of the IVF procedure and monozygotic multiple pregnancies remains controversial.

The Role of GnRH-Analogues used in Elderly (&gt;38 yrs) Patients Undergoing Controlled Ovarian Hyperstimulation for IVF

Objectives: To examine the influence of type of GnRH-analogue used, on reproductive outcome of elderly patients (> 38 years old) undergoing controlled ovarian hyperstimulation (COH) for IVF. Patients and Methods: We studied 2436 consecutive cycles, 1369 in the agonist group and 1067 in the antagonist group. Infertility-treatment-related variables and pregnancy rates were compared between young (<38 years) and elderly patients and between those undergoing the GnRH-agonist or antagonist COH protocols. Results: While a significantly higher pregnancy rate was observed in young patients undergoing the GnRH-agonist as compared to the GnRH-antagonist COH protocols (30.1% vs 21.1%, respectively; p<0.001), no difference was demonstrated in elderly patients. Conclusions: The long GnRH agonist suppressive protocol has a clear advantage over the GnRH antagonist in young patients with favorable outcome- a priori, but not in elderly patient undergoing COH for IVF.

Experimental research Comparisons of the effects of long-acting and short-acting GnRH agonists on embryo quality, endometrial thickness and pregnancy rate in human in vitro fertilization

IntroductionThe aim was to compare the efficacy of long-acting and short-acting gonadotropin-releasing hormone (GnRH) agonists by long protocol on embryo quality, endometrial thickness and pregnancy rate in in vitro fertilization.Material and methodsIn this retrospective study, long-term pituitary downregulation, achieved with long- and short-acting GnRH agonists (GnRHa), was performed for patients undergoing in vitro fertilization (n = 175).ResultsThere were no significant differences between the long and short-acting GnRH group (63.16% vs. 66.26%, p > 0.05), and the secondary and primary infertility group (63.47% vs. 66.86%, p > 0.05) in embryo quality. Logistic regression analysis showed that type of infertility and endometrial thickness were significantly associated with pregnancy outcome. Patients in the long-acting GnRHa group had a thicker endometrium on the day of human chorionic gonadotrophin (hCG) administration (10.79 ±2.62 mm vs. 9.64 ±1.97 mm, p < 0.01), lower serum luteinizing hormone (LH) concentration (1.21 ±1.13 vs. 2.53 ±3.39) and a higher pregnancy rate (59.60% vs. 43.42%, p < 0.05) than those of patients in the short-acting GnRHa group.ConclusionsThis work suggests that types of agonist protocol and infertility may not affect embryo quality. Type of infertility and endometrial thickness may be positive predictors for clinical pregnancy, but the key finding is that the long-acting GnRHa protocol may be an effective method of improving endometrial thickness, endometrial receptivity and pregnancy rate in in vitro fertilization.