Gonadotropin-releasing Hormone Agonist Suppression Research Articles

Evaluation of Early Frozen Blastocyst Transfer in A True Natural Cycle Protocol in Comparison to A Hormone Replacement Protocol: A Single-Center Cohort Study.

Timing of frozen embryo transfer (FET) within a purported window of implantation is of increasing interest, and there is a paucity of evidence surrounding the transfer of frozen embryos early within these frozen embryo transfer protocols. This study aimed to evaluate whether live birth rates were equivalent after FET of blastocysts 4 days after luteinizing hormone (LH) surge in a true natural cycle protocol, compared to a hormone replacement (HR) protocol. Single-centre, retrospective cohort study involving patients undergoing autologous frozen blastocyst transfer from January 1st, 2013, to December 31st, 2016. Cycles were grouped according to their protocol: true natural cycle (hormonal detection of LH surge with FET scheduled four days later) versus HR cycle (luteal phase gonadotropin-releasing hormone agonist suppression, oral or vaginal estradiol and intramuscular progesterone starting five days before FET). A total of 850 cycles were included, 501 true natural cycles and 349 HR cycles. The primary outcome was the live birth rate, secondary outcomes included clinical pregnancy rate and miscarriage. Logbinomial regression models were performed adjusting for a priori selected variables. Adjusted resulted in live birth rates of 38.7 and 40.4%, [adjusted risk ratio (aRR): 0.96, 95% confidence interval (CI): 0.76-1.22, P=0.729] in the natural cycle and HR groups, respectively. The secondary outcome analyses did not demonstrate any statistically significant difference in the rate of positive human chorionic gonadotropin (hCG), clinical intrauterine pregnancy rate, or miscarriage rate. The timing of the FET four days after LH surge in a true natural cycle protocol results in equivalent live birth rates compared to a HR protocol. Results of this study suggest that the window of implantation within the natural cycle may be less finite than currently believed and further prospective studies evaluating the timing of frozen embryo transfer are warranted.

Endometrial preparation for frozen-thawed embryo transfer cycles: a systematic review and network meta-analysis.

To compare the effects of different endometrial preparation protocols for frozen-thawed embryo transfer (FET) cycles and present treatment hierarchy. Systematic review with meta-analysis was performed by electronic searching of MEDLINE, the Cochrane Library, Embase, ClinicalTrials.gov and Google Scholar up to Dec 26, 2020. Randomised controlled trials (RCTs) or observational studies comparing 7 treatment options (natural cycle with or without human chorionic gonadotrophin trigger (mNC or tNC), artificial cycle with or without gonadotropin-releasing hormone agonist suppression (AC+GnRH or AC), aromatase inhibitor, clomiphene citrate, gonadotropin or follicle stimulating hormone) in FET cycles were included. Meta-analyses were performed within random effects models. Primary outcome was live birth presented as odds ratio (OR) with 95% confidence intervals (CIs). Twenty-six RCTs and 113 cohort studies were included in the meta-analyses. In a network meta-analysis, AC ranked last in effectiveness, with lower live birth rates when compared with other endometrial preparation protocols. In pairwise meta-analyses of observational studies, AC was associated with significant lower live birth rates compared with tNC (OR 0.81, 0.70 to 0.93) and mNC (OR 0.85, 0.77 to 0.93). Women who achieved pregnancy after AC were at an increased risk of pregnancy-induced hypertension (OR 1.82, 1.37 to 2.38), postpartum haemorrhage (OR 2.08, 1.61 to 2.78) and very preterm birth (OR 2.08, 1.45 to 2.94) compared with those after tNC. Natural cycle treatment has a higher chance of live birth and lower risks of PIH, PPH and VPTB than AC for endometrial preparation in women receiving FET cycles.

Successful oocyte cryopreservation using letrozole as an adjunct to stimulation in a transgender adolescent after GnRH agonist suppression

To report a successful case of ovarian hyperstimulation and oocyte cryopreservation in a transgender male adolescent after suppression with a gonadotropin-releasing hormone (GnRH) agonist while using the aromatase inhibitor letrozole to maintain low serum estradiol. Case report. Division of Reproductive Endocrinology and Infertility, Washington University in St. Louis School of Medicine, St Louis, Missouri. A 15-year-old Tanner II transgender male adolescent with a GnRH agonist implant. The GnRH agonist implant was removed. The patient was given letrozole (5 mg daily) while undergoing ovarian stimulation with an antagonist protocol. After oocyte retrieval, the patient began taking testosterone. Successful oocyte cryopreservation with minimal changes in breast budding. The patient's peak serum estradiol concentration was 510 pg/mL. Twenty-two mature oocytes were cryopreserved. Small increases in breast budding occurred between baseline and the time of oocyte retrieval. We successfully used letrozole to maintain low serum estradiol in a transgender male adolescent during ovarian stimulation. Maintaining low estradiol to minimize pubertal development and possibly prevent gender dysphoria symptoms may make oocyte cryopreservation more desirable for transgender male adolescents.

Pregnancy Outcomes Following Letrozole Use in Frozen-thawed Embryo Transfer Cycles: A Systematic Review and Meta-analysis.

While widely used for ovulation induction in assisted reproductive technology, the clinical efficacy of letrozole for endometrial preparation prior to frozen-thawed embryo transfer (FET) cycles remains yet to be elucidated. We performed a meta-analysis to compare pregnancy outcomes after letrozole use with those of other endometrial preparation protocols in patients undergoing FET. PubMed, Scopus, Embase and the Cochrane Library were searched for eligible studies. Clinical pregnancy rate (CPR), live birth rate (LBR) and birth defect rate (BDR) were analysed using odds ratio (OR) and 95% confidence interval (CI). A total of 10 studies representing 75 968 FET cycles were included. Comparable CPR and LBR were observed when comparing letrozole administration with natural cycle (OR 1.24, 95% CI: 0.69 – 2.24; OR 1.18, 95% CI: 0.60 – 2.32), artificial cycle (OR 1.46, 95% CI: 0.87 – 2.44; OR 1.39, 95% CI: 0.77 – 2.52), and artificial cycle with gonadotropin-releasing hormone agonist suppression (OR 1.11, 95% CI: 0.78 – 1.59; OR 1.18, 95% CI: 0.82 – 1.68). Pooled results of the limited studies comparing letrozole with human menopausal gonadotropin demonstrated a similar CPR between groups (OR 1.46, 95% CI: 0.29 – 7.21, two studies), but the letrozole group had a statistically lower LBR (OR 0.67, 95% CI: 0.52 – 0.86, one study). No increased BDR was observed in the letrozole group compared to natural cycles or artificial cycles (OR 0.98, 95% CI: 0.60 – 1.61; OR 1.39, 95% CI; 0.84 – 2.28). This pooled analysis supports the use of letrozole as an efficacious and safe alternative to mainstream regimens for endometrial preparation in FET cycles.

Cycle regimens for frozen-thawed embryo transfer.

Cycle regimens for frozen-thawed embryo transfer.

Serum concentrations of HE4 change little during in vitro fertilization

Human epididymal secretory protein 4 (HE4) is a biomarker for ovarian cancer. The effect of follicle stimulating hormone (FSH) stimulation during in vitro fertilization (IVF) on HE4 was evaluated to determine whether substantial hormonal stimulation of the ovaries affects the serum levels of this marker. Findings were compared with serum concentrations of cancer antigen 125 (CA125), currently the most commonly used marker for ovarian cancer. Prospective cohort study. University hospital infertility clinic. Infertility patients undergoing IVF treatment. We determined the serum concentration of HE4 and CA125 in serial blood samples in 20 women treated with IVF. Samples were taken following gonadotrophin-releasing hormone agonist suppression, two to three times during FSH stimulation, at ovum pick-up and 2weeks following embryo transfer at the time of the pregnancy test. Ovarian follicles were counted and serum estradiol concentrations measured throughout treatment. Serum HE4, CA125 and estradiol concentrations. Serum HE4 levels did not increase significantly during the FSH stimulation. The majority of values remained below the normal reference range (<70pm) throughout the treatment. Serum CA125 concentration also remained low during stimulation. Serum estradiol concentration reflected the severity of ovarian stimulation during IVF, increasing 3.9-fold with stimulation. Serum HE4 concentrations respond little if at all to supraphysiological ovarian stimulation, suggesting that the amount of circulating HE4 in women with normal ovaries is independent of gonadotropin stimulation. Hormonal stimulation of the ovaries is unlikely to affect the differential diagnosis of ovarian tumors with HE4.

Factors associated with monozygosity in assisted reproductive technology pregnancies and the risk of recurrence using linked cycles

To evaluate factors associated with monozygosity (MZ) (number of fetal heartbeats on early ultrasound greater than the number of embryos transferred) and the risk of recurrence in subsequent pregnancies using a national assisted reproduction database. Historical cohort study. Clinic-based data. 197,327 pregnancies (including 2,824 with evidence of MZ) from cycles reported to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) between 2004 and 2010. None. Evidence of MZ, adjusted odds ratios and their 95% confidence intervals computed from logistic regression models. In the univariate analysis, the risk of MZ was increased with ovulation disorders, donor oocytes, gonadotropin-releasing hormone agonist (GnRH-a) suppression, assisted hatching (AZH), and day 5-6 transfer, and was decreased with higher follicle-stimulating hormone (FSH) doses (≥3,000 IU). In the multivariate analysis, the risk of MZ was increased with GnRH-a suppression, AZH, and decreased with intracytoplasmic sperm injection (ICSI) and higher FSH dose. The interaction showed that although MZ was more likely with day 5-6 embryos, AZH had a minimal nonsignificant effect, whereas in day 2-3 embryos, AZH had a substantial statistically significant effect. Only one woman had a recurrence of MZ in a subsequent assisted reproduction pregnancy, which is consistent with randomness. The risk of MZ was higher with fresh day 5-6 embryos, donor oocytes, GnRH-a suppression, lower FSH doses, and AZH (particularly with day 2-3 embryos).

Effectiveness of HP-hMG versus r-FSH in patients undergoing IVF/ICSI cycles with moderate male-factor infertility

The aim of this case-control study was to compare the efficacy of highly purified human menopausal gonadotropin (HP-hMG) versus recombinant follicle stimulating hormone (r-FSH) treatments following gonadotropin-releasing hormone (GnRH) agonist suppression in patients undergoing intracytoplasmic sperm injection (ICSI) with moderate male-factor infertility in terms of oocyte and embryo quality and clinical pregnancy outcomes. Materials and methods: A total of 240 infertile women were treated with HP-hMG (HP-hMG group, n = 120 patients) or r-FSH (r-FSH group, n = 120 patients) following GnRH agonist suppression (long regimen). Inclusion criteria for the study groups were infertility due to moderate oligoasthenoteratospermia with no associated female infertility factor, fewer than 2 previous assisted reproductive technology cycles, and female patients with ages between 19 and 35 years, normal basal FSH, regular ovulatory cycles, and body mass index below 30 kg/m^2. Results: Treatment durations and gonadotropin doses were similar in both groups. Cycle cancellation rates, clinical pregnancy and miscarriage rates, total and metaphase II oocytes retrieved, fertilization rate, and number of embryos transferred were all similar in both groups. The clinical pregnancy rates were 45.9% (n = 50/109) in the r-FSH group and 40.4% (n = 44/109) in the HP-hMG group. Conclusion: HP-hMG is as effective as r-FSH in terms of oocyte and embryo quality and clinical pregnancy outcomes in patients undergoing ICSI with moderate male-factor infertility.

Ovarian Cyst Formation Following Gonadotropin-Releasing Hormone-Agonist Administration Decreases the Oocyte Quality in IVF Cycles.

The gonadotropin-releasing hormone-agonist (GnRH-a) treatment during in vitro fertilization (IVF) sometimes causes a functional ovarian cyst during the administration period before gonadotropin stimulation, as an undesired event. The aim of this study was to analyze the effect of these cysts on the IVF outcomes. Out of 981 IVF cycles, 78 with ovarian cysts were retrospectively analyzed with respect to the demographic characteristics, hormonal outcomes, and fertilization, implantation and clinical pregnancy rates. The metaphase II oocyte ratio, fertilization rate and percentage of high quality embryos (grade 1) were significantly higher in the cyst-negative group (p<0.0001; p<0.0001; p≤0.05). These same three parameters were also significantly higher in the cyst-aspirated group (p<0.01; p<0.05; p<0.05). Cyst diameters of the aspiration group were significantly higher (p<0.05). No statistically significant differences in implantation and clinical pregnancy rates were determined between the groups. An ovarian cyst formation during the GnRH-a suppression period negatively affects oocyte quality. Cyst aspiration before gonadotropin stimulation does not improve the IVF outcome.

Use of hormone suppression then oocyte freezing to preserve reproductive capability in an adolescent girl with ovarian luteinized thecoma associated with sclerosing peritonitis

To describe a case of ovarian luteinized thecoma, a rare ovarian neoplasm, which is only the 26th reported case associated with sclerosing peritonitis. Case report. NYU Fertility Center and Memorial Hospital for Cancer and Allied Diseases, New York. A 17-year-old woman presenting with a large pelvic mass and abdominal pain. Conservative surgical treatment with laparotomy, unilateral salpingooophorectomy, and biopsy of contralateral ovary. Gonadotropin-releasing hormone agonist suppression. Ovarian hyperstimulation with oocyte retrieval/freezing to preserve biologic fertility. Response to conservative therapy and oocyte cryopreservation as a method of fertility preservation. At laparotomy, obvious unilateral ovarian involvement was present, and a left salpingoophorectomy was performed. Biopsy of the contralateral ovary confirmed bilateral disease. The initial pathological review was complicated by extensive ovarian edema. The patient was treated with gonadotropin-releasing hormone agonist suppression plus intermittent estradiol supplementation. When she became intolerant of hormone therapy and when removal of the remaining ovary became a possibility, she underwent ovarian hyperstimulation; oocyte retrieval and freezing were performed to preserve her biologic fertility. Thirty-eight eggs were obtained. Surgically diagnosed luteinized thecoma can be managed medically. Oocyte cryopreservation as a means of fertility preservation should be considered in young women with this diagnosis who are at risk for bilateral gonad removal.

Age-Specific Levels for Basal Follicle-Stimulating Hormone Assessment of Ovarian Function

Traditionally, the most important measurement in the assessment of ovarian function has been age-independent baseline follicle-stimulating hormone (FSH) levels. The objective of this study was to characterize the continuum of ovarian function based on age-specific categories of baseline FSH. In a cross-sectional historical cohort study we evaluated records of 434 patients with baseline FSH levels of less than 12 milli international units/mL that underwent ovulation induction for in vitro fertilization (IVF) with long gonadotropin-releasing hormone (GnRH) antagonist or GnRH agonist suppression and modal gonadotropin stimulation of 300 units of gonadotropins per day. In these patients with apparent normal ovarian function by current baseline FSH criteria and with routine ovarian stimulation, we assessed IVF cycle outcomes, including oocyte yields, based on age-specific baseline FSH levels, defined as levels less than or equal to the 95% confidence interval for each age group. Age-specific baseline FSH levels predicted the retrieval of fewer than or equal to four oocytes, with a positive predictive value of 19.5% and a negative predictive value of 88%. The Mantel-Haenszel common odds ratio for fewer than or equal to 4 oocyte production in the presence of premature ovarian aging was 2.8 (95% confidence interval 1.52-5.17; P<.001). These results suggest that, within generally accepted normal baseline FSH values, women with baseline FSH above the 95% confidence limits for age produce fewer oocytes in response to normal ovulation induction protocols compared with other women their age.

P-41: Effects of ovulation during endometrial preparation on the outcomes of cryopreserved-thawed blastocyst transfer cycles

Blastocyst transfer provides the ability to reduce the incidence of high order multiple pregnancy while optimizing pregnancy rates. Cryopreserved-thawed blastocyst transfer significantly may improve cumulative pregnancy rate. Cryopreserved-thawed embryo transfer has been successfully performed in ovulatory cycles such as natural cycles or ovulation induction cycles, and in non-ovulatory cycles in which the endometrium is artificially prepared with exogenous hormone supplementation. However, there are few available reports on the impact of ovulation during endometrial preparation in cryopreserved-thawed embryo transfer cycles. We compared clinical outcomes between ovulatory and non-ovulatory cycles to evaluate whether ovulation affected the outcomes during endometrial preparation in cryopreserved-thawed blastocyst transfer cycles. Prospective observational study. Sixty-eight patients who underwent cryopreserved-thawed blastocyst transfer from Jun 2005 to Mar 2006 were included in this study and divided into two groups: non-ovulatory group (n=33) and ovulatory group (n=35). In non-ovulatory group, endometrial preparation was achieved by oral estradiol valerate and intramuscular progesterone without prior gonadotropin-releasing hormone agonist suppression. Ovulatory group included natural cycles (n=17) and ovulation induction cycles using clomiphene citrate (n=9) or letrozole (n=9). We compared clinical characteristics and pregnancy outcomes, which were statistically analyzed using Mann-Whitney U-test and Fisher’s exact test where appropriate. The duration of endometrial preparation was significantly shorter in ovulatory group compared to non-ovulatory group (14.6±1.3 days vs. 13.9±1.7 days, p=0.042). Although there was no significant difference in the mean endometrial thickness on the day of progesterone or hCG administration between the two groups, triple endometrial patterns were more frequently observed in ovulatory group (18/33 (54.5%) vs. 30/35 (85.7%), p=0.007). However, there were no significant differences between the two groups with regard to the implantation and clinical pregnancy rates per embryo transfer.Tabled 1Tabled 1 These findings suggest that ovulation during endometrial preparation does not have any significant effect on the pregnancy outcomes. Both ovulatory and non-ovulatory cycles may be equally effective for endometrial preparation in cryopreserved-thawed blastocyst transfer cycles.

Determination of the efficiency of controlled ovarian hyperstimulation in the gonadotropin-releasing hormone agonist-suppression cycle using the initial follicle count during gonadotropin stimulation.

Our purpose was to evaluate the relationship between the initial follicle count during gonadotropin stimulation after gonadotropin-releasing hormone (GnRH) agonist suppression and the efficiency of controlled ovarian hyperstimulation (COH) in patients receiving treatment with assisted reproductive technologies (ARTs). A total of 338 COH procedures in 291 couples was performed with cycles that reached the stage of oocyte retrieval. The ovarian antral follicle number was measured using transvaginal ultrasonography at the folliculometry during gonadotropin stimulation by GnRH agonist suppression in patients undergoing ARTs. Controlled ovarian hyperstimulation was accomplished using GnRH agonist down-regulation combined with FSH and menotropin stimulation. The characteristics of oocytes after retrieval and embryos after in vitro culture and the pregnancy rates were assessed. The procedures performed included 195 ET cycles, 129 TET cycles, and 14 incomplete cycles. The treatment cycles were divided into four categories according to the antral follicle number (i.e., < or = 5, 6-10, 11-15, and > or = 16) at the first folliculometry to evaluate the influence of various factors. The antral follicle count correlated significantly with the patient age, dosage of gonadotropins, serum estradiol concentration, number of antral follicles (> or = 13 mm) while receiving hCG injections, number of oocytes retrieved, and, later, number of embryos transferred. There was a trend toward an increasing number of pregnancies per cycle as the number of antral follicles increased (14.7, 26.5, 44, and 45%, respectively). We were able to predict the efficiency of COH and outcome of ARTs based on the follicle count during the first folliculometry during gonadotropin stimulation after GnRH agonist suppression. The results of the folliculometry significantly predicted the ovarian response to COH and the outcome of ARTs in the current treatment cycle.

A flexible protocol for artificial preparation of the endometrium without prior gonadotropin-releasing hormone agonist suppression in women with functioning ovaries undergoing frozen-thawed embryo transfer cycles

Objective: To present our experience with a flexible and convenient protocol for artificial endometrial preparation without prior GnRH agonist suppression in patients with functioning ovaries undergoing frozen ET. Design: Case series. Setting: An IVF unit in a university hospital. Patient(s): All patients who underwent IVF with embryo cryopreservation from December 1997 to June 1998 and requested transfer of their frozen-thawed embryos. Intervention(s): Controlled endometrial preparation for ET entailed the use of a fixed dose of 6 mg/d of micronized E 2 started on day 1 of the cycle, followed by concomitant administration of micronized P placed in the vagina. Main Outcome Measure(s): Hormonal and endometrial profiles throughout the cycle, pregnancy rate per ET, implantation rate, and pregnancy outcome. Result(s): Of 185 treatment cycles in 140 patients, 8 cycles (4.3%) were canceled. In another 2 cycles, no embryos were suitable for transfer. For the remaining 175 ET cycles, the calculated pregnancy rate and implantation rate were 21.7% and 9%, respectively. The proliferative phase could be extended up to 20 days but was a mean (±SD) of 15 ± 1.9 days. Conclusion(s): For patients with functioning ovaries, controlled endometrial preparation for the transfer of frozen-thawed embryos can be done successfully by using oral E 2 from day 1 of the cycle followed by P preparation. Prior suppression with GnRH agonist is not necessary.

Pulsatile gonadotrophin secretion in women with polycystic ovary syndrome after gonadotrophin-releasing hormone agonist treatment.

In polycystic ovary syndrome (PCOS), increased luteinizing hormone (LH) pulse frequency has been attributed to either the hypothalamic gonadotrophin-releasing hormone (GnRH) pulse generator or ovarian oestrogen feedback. To address this issue, a detailed examination of pulsatile LH secretion was undertaken during recovery from GnRH agonist (GnRHa) suppression. Each of six women with PCOS and six normal ovulatory women received daily GnRHa treatment for 14 weeks. Frequent blood samples were collected and assayed for gonadotrophins, androgens and oestrogens before, during and up to 4 weeks after treatment. Women with PCOS had higher basal LH pulse frequency and amplitude and increased serum concentrations of LH, androstenedione, testosterone and oestrone than controls. After 3 months of GnRHa treatment, all these parameters were suppressed with no differences observed between the two groups. One week after cessation of GnRHa, LH pulse frequency promptly returned to pre-treatment range with no between-group differences noted, whereas LH pulse amplitude, serum gonadotrophins and ovarian steroids remained maximally suppressed and equivalent in the two groups. Subsequent LH pulse frequency remained constant while LH pulse amplitude and circulating concentrations gradually increased in parallel with a return of serum oestrogen to pre-treatment values. Despite comparable resumption of LH secretion in the two groups, corresponding androgen concentrations in women with PCOS were greater than those of normal ovulatory women. Thus, the immediate restoration of LH pulse frequency after discontinuing GnRHa treatment is largely independent of ovarian oestrogen production and reflects primacy of the GnRH pulse generator in determining basal LH pulse frequency. Equivalent LH pulse frequency rates in the two groups during the recovery period do not suggest an intrinsic hypothalamic-pituitary hyperactivity in PCOS.

Transfer of cryopreserved-thawed pre-embryos in a cycle using exogenous steroids without prior gonadotrophin-releasing hormone agonist suppression yields favourable pregnancy results.

We have analysed the use of a programmed cycle of administration of exogenous steroids without prior suppression with a gonadotrophin-releasing hormone agonist (GnRHa) for the transfer of cryopreserved-thawed pre-embryos. From July 1992 to June 1994, 199 cycles (162 patients) were studied. Pre-embryos had been previously cryopreserved at the pronuclear stage using 1.5 M 1,2-propanediol as a cryoprotectant. Preparation of the endometrium was achieved in a step-up regime with transdermal oestradiol patches (0.1 to 0.4 mg). Progesterone in oil (50 mg i.m.) was started on cycle day 13. Pre-embryos were thawed on day 14 and transferred on day 15 after evidence of survival and cleavage. The mean (+/- SD) age of patients undergoing transfer was 35.4 +/- 4.3 years. The mean number of pre-embryos thawed was 4.7 +/- 1.8 with a mean of 3.3 +/- 1.4 pre-embryos being transferred. Eight of the cycles demonstrated follicular development >16 mm prior to thaw and transfer; however, these patients did not demonstrate a luteinizing hormone surge. Mean endometrial thickness on day 13 was 10.8 +/- 2.1 mm. Overall pregnancy rate was 29.2% (57/195). The ongoing or delivery rate was 16.1% (32/195). The rate of preclinical losses per transfer was 6.2% (12/195). Overall, the implantation rate was 6.2% (47/757). Thus, the use of a programmed cycle for cryopreserved embryo transfer yields favourable pregnancy outcome and offers practical advantages to patients. Prior suppression with a GnRHa is not necessary for endometrial preparation.

Comparison of GnRH Agonist Administration Before and After Laparoscopic Drainage of Endometriomas

Our purpose was to assess the most proper time for initiation of gonadotropin-releasing hormone agonist (GnRH-a) therapy combined with laparoscopic drainage. The first group included 13 women with 18 endometriomas (5 bilaterally) in whom drainage of the endometrioma during initial laparoscopy was followed by ovarian suppression with GnRH-a therapy. The second group consisted of 12 women with 17 endometriomas. These patients received GnRH-a during the luteal phase of the cycle and underwent laparoscopic drainage after menstruation. Both groups recieved GnRH-a therapy for 6 months, and a second-look laparoscopy was performed to assess the results in all cases. Complete resolution was found in 33.3% of patients in the first group compared with 58.8% in the second group. Of the persistent cases, partial resolution (decrease in cyst size) was found in all cases in both groups. However, at 1-year follow-up, persistence of the endometriomas was found in 83.3% of group 1 and 52.9% of group 2. According to these findings, we conclude that drainage of endometrioma with perioperative GnRH-a therapy cannot be considered the treatment of choice. However, GnRH-a therapy initiated before laparoscopic drainage has better outcomes compared with GnRH-a suppression after laparoscopic drainage. (J GYNECOL SURG 13:17, 1997)

Pregnancy and birth after high serum progesterone concentrations during the follicular phase in an in-vitro fertilization cycle with gonadotrophin-releasing hormone agonist suppression

This case illustrates the possibility of achieving a pregnancy and birth when elevated progesterone concentrations (> 4 ng/ml) are present during the follicular phase (from 6 days before human chorionic gonadotrophin injection) of a gonadotrophin-releasing hormone agonist/menotrophin cycle for in-vitro fertilization (IVF). The present patient underwent three IVF/embryo transfer cycles in which progesterone concentrations were repeatedly increased from the midfollicular phase onwards. A pregnancy was achieved after the first IVF attempt but ended in a miscarriage in the 19th week of gestation. During the second IVF attempt an endometrial biopsy taken on the day of oocyte retrieval revealed an endometrial advancement of 2 days. A successful pregnancy and birth was again achieved after the third IVF attempt although progesterone concentrations were considerably increased from 6 days before the ovulatory stimulus.

Sequential estrogen-progestin addition to gonadotropin-releasing hormone agonist suppression for the chronic treatment of ovarian hyperandrogenism: a pilot study

Sequential estrogen-progestin addition to gonadotropin-releasing hormone agonist suppression for the chronic treatment of ovarian hyperandrogenism: a pilot study

Sequential estrogen-progestin addition to gonadotropin-releasing hormone agonist suppression for the chronic treatment of ovarian hyperandrogenism: a pilot study.

The purpose of the study was to evaluate the efficacy and safety of a sequential regimen of estrogen-progestin addition to GnRH agonist suppression in ovarian hyperandrogenism. Eight patients presenting with a polycystic ovary syndrome were treated with an sc implant of GnRH agonist every 4 weeks for 48 weeks. Starting at week 9, patients were replaced with 100 micrograms transdermal estradiol patches continuously and sequentially combined with 10 mg oral medroxyprogesterone acetate the last 2 weeks of each 4-week period. The rapid down-regulation of the pituitary-ovarian axis led to significant reduction of testosterone and androstenedione to 48.9% and 67.4% of baseline, respectively. During steroid replacement, testosterone and androstenedione continued to decrease gradually. The baseline hirsutism score (18.7 +/- 1.3) progressively fell to 9.7 +/- 2.0 at the end of treatment. The mean hair diameter was significantly reduced (0.097 +/- 0.004 vs. 0.081 +/- 0.005 mm). A withdrawal bleeding was obtained in 63.6% of the artificial cycles, but breakthrough bleeding occurred during 48% of the sequential replacements. The incidence of menopausal symptoms was low. There was a nonsignificant decrease in bone mineral content of the lumbar spine and the femoral neck but no trend in Ca2+/creatinine and OH-proline (OH-P)/creatinine ratios or in serum triglycerides and cholesterol fractions. There was a nonsignificant increase in hirsutism score in five patients followed up for 24 weeks after cessation of treatment, although there was a rapid return of hormones toward baseline and recurrence of irregular bleeding. Transdermal estradiol addition periodically combined with medroxyprogesterone acetate is effective in reducing hirsutism and is safe in minimizing side effects and bone loss. A regimen allowing a better bleeding control would make this approach a valuable alternative for prolonged or repeated palliative treatment of excessive hair growth and irregular bleeding in polycystic ovary syndrome.