Methods Of Ovarian Stimulation Research Articles

O-069 The first mitotic spindle instability impacts nucleation, fragmentation, and development in human embryos

Abstract Study question How multinucleation and fragmentation occur in the first mitosis in human embryos? Summary answer The first mitotic spindles had heterogeneity, and the shapes and movements of the spindles were strongly associated with multinucleation and fragmentation. What is known already Studies have shown that many problems occur during the first mitosis, such as fragmentation and multinucleation. However, the cell biologic mechanisms whereby these errors occur during the first mitosis in human embryos remain unknown. To clarify this aspect, it is necessary to analysis the dynamics of DNA and cytoskeleton using live human embryos. Although microinjections of DNA or mRNA into mammalian embryos were widely used for live imaging during early mitosis, the method into human poses the risk of ethical issues. Therefore, we established a method used for real-time imaging in human embryos using chemical fluorescent labeling. Study design, size, duration Frozen human two-pronuclear stage embryos were donated for research by couples who had completed fertility treatment. We obtained written informed consent from patients who donated human embryos. The mean age of patients at embryo freezing was 32.00 ± 3.03 (SD) years. We imaged thirty-one living human embryos using chemical fluorescent labeling and confocal microscopy to visualize DNA and tubulin. Participants/materials, setting, methods Thirty-one human embryos were cultured in medium containing the live-cell stain probes SPY555-DNA and SPY650-Tubulin. The Embryos were imaged using an LSM980 laser scanning confocal microscope every 10–20 min for a period of eight hours. Three-dimensional (3D) visualizations of human embryos were performed using the Imaris software. The first spindle shapes were quantified by image analysis and calculated the aspect ratio of the spindles using ImageJ. Main results and the role of chance We discovered that over 81% of two-pronuclear zygotes became multinucleated 2-cell stage embryos. We demonstrated that there was variation in the first mitotic spindles. There was a significant difference between the aspect ratio (AR) of the spindles leading to the mononuclear and multinuclear types at the 2-cell stage (p < 0.005). In addition, the low-AR spindles were unstable and often had more defocused poles than the high-AR spindles, which lead to multinucleation at the 2-cell stage (55 % vs. 0%, p < 0.05). More embryo having high-aspect ratio spindles tend to develop blastocysts than those having low aspect-ratio spindles (p < 0.05). Moreover, the movement of the central spindles varied after chromosome segregation. The embryos with more fragments at two cell stage had a significantly longer period for the central spindles to transform into midbodies compared to those with fewer fragments. The central spindles of embryos with more fragments moved a longer distance from the beginning of furrow ingression to the completion of the first division (p < 0.05). These results suggest that the first mitotic spindle instability and heterogeneity cause many errors such as multinucleation, fragmentation, and embryonic development. Limitations, reasons for caution Imaged human embryos were donated from a fertility clinic, and detailed patient information, such as underlying disease and method of ovarian stimulation, was not available. It is possible that the human zygotes used in this study had a bias in patient characteristics. Wider implications of the findings Our study showed that there were instability and heterogeneity in the first mitotic spindle, which was strongly associated with multinucleation, fragmentation, and embryonic development. Revealing the mechanism underlying spindle formation in cleavage-stage embryos will contribute to improving the success rate of assisted reproduction technologies in humans. Trial registration number not applicable

Clinical and laboratory factors associated with the presence of dysmorphic oocytes in intracytoplasmic sperm injection cycles.

This study investigated the clinical and laboratory factors associated with the presence of dysmorphic oocytes in intracytoplasmic sperm injection (ICSI) cycles. The study involved 200 ICSI cycles, performed from 2020 to 2021, that yielded at least one mature oocyte. Clinical characteristics and ovarian stimulation methods were compared between 68 cycles with at least one dysmorphic oocyte (the dysmorphic group) and 132 cycles with normal-form oocytes only (the non-dysmorphic group). Dysmorphic oocytes were characterized by dark cytoplasm, cytoplasmic granularity, cytoplasmic vacuoles, refractile bodies in the cytoplasm, smooth endoplasmic reticulum in the cytoplasm, an oval shape, an abnormal zona pellucida, a large perivitelline space, debris in the perivitelline space, or an abnormal polar body. The ages of the women, indications for in vitro fertilization, serum anti-Müllerian hormone levels, and rates of current ovarian endometrioma were similar between the dysmorphic and non-dysmorphic groups. In both groups, the three ovarian stimulation regimens, two types of pituitary suppression, and total gonadotropin dose were employed similarly. However, the dual-trigger method was used more frequently in the dysmorphic group (67.6% vs. 50%, p=0.024). The dysmorphic group contained significantly more immature oocytes and exhibited significantly lower oocyte maturity (50% vs. 66.7%, p=0.001) than the non-dysmorphic cycles. Within the dysmorphic group, significantly lower oocyte maturity was found in the cycles using a dual-trigger, but not in those with a human chorionic gonadotropin trigger. ICSI cycles with dysmorphic oocytes are closely associated with reduced oocyte maturity. This association was observed exclusively in dual-trigger cycles.

Introduce an optimal method of ovarian stimulation in the polycystic ovarian syndrome affected: a randomized controlled trial

BackgroundCurrently, optimal method of ovarian stimulation (OS) to in-vitro fertilization (IVF) in the patients with polycystic ovarian syndrome (PCOS) is unknown. The present research aims to study the efficiency of minimal-OS method in treatment of infertile patients with PCOS and also the effect of gonadotropin type (recombinant FSH (r-FSH) vs. urinary Human menopausal gonadotropin (u-HMG)) on treatment cycles with GnRH-antagonist.MethodsIn this randomized controlled trial, a total of 120 eligible patients were randomly allocated into four groups of OS to IVF: minimal-OS with r-FSH, minimal-OS with u-HMG, mild-OS with r-FSH and mild-OS with u-HMG. IVF outcomes of groups were analyzed statically.ResultsThe statistical analysis showed that there were significant differences among groups regarding stimulation duration (p < 0.0001), number of retrieved oocytes (p < 0.0001), number of obtained embryos (p < 0.0001). There were no statistically significant differences in fertilization rate (p = 0.289) and implantation rate (p = 0.757) among our participants. There were also significant differences among these four groups in terms of clinical pregnancy rate (/ET and /cycles) (p < 0.0001, p = 0.021, respectively) and live birth rate/cycles (p < 0.0001). Also cases of freeze all embryos due to prevention of ovarian hyper stimulation syndrome (OHSS) (p = 0.004).ConclusionsOn the basis of present results the minimal-OS with u-HMG may be one of optimal methods of control OS in the patients with PCOS in respect to serum levels of estradiol on the day of triggering final oocyte maturation, total dose of prescribed gonadotropin, the optimal number of oocytes and embryos obtained, rate of clinical pregnancy and the incidence of OHSS risk.Trial registrationNCT, NCT03876145. Registered 15/03/2019. Retrospectively registered, http://www.clinicaltrial.gov/ NCT03876145.

Ovarian stimulation methods at a single-assisted reproductive technology institution: a retrospective study of successful outcomes

Aim : to examine an efficacy of various stimulation methods in a group of successful pregnancies. Materials and Methods . In a single center retrospective study 47 pregnancy cases were examined after performing embryo transfers at our institution from the years 2017 to 2021. Patients were divided into four groups: i) clomiphene hyperstimulation (CH), ii) stimulation with gonadotropin-releasing hormone (GnRH) agonist, iii) with GnRH antagonist, and iv) progestin-primed ovarian stimulation (PPOS). Age, anti-Mullerian hormone, presence of chronic disease, number of in-vitro fertilizations prior to conception, dosage of follicle stimulating hormone (FSH), presence of premature luteinizing hormone surge, number of egg retrievals, fertilization rate, and live birth rate were assessed. Results. The number of pregnancies obtained by CH, agonist, antagonist, and PPOS methods comprised 25, 12, 2, and 8 cases, respectively. No significant difference in parameters between CH group and non-CH groups, excepting FSH was observed. The FSH was used in CH group and non-CH group at dose of 1108 ± 468 IU and 1756 ± 394 IU, respectively (p &lt; 0.0001). Conclusion. CH is not commonly used due to potential luteal phase defects, but it is thought to be cost-effective, requiring lower FSH doses, requiring no ovulation suppression antagonists, and exerting no effect on frozen embryos or fetuses. Hence, CH could be a suitable protocol for egg retrieval in Japan.

Low risk of OHSS with follitropin delta use in women with different polycystic ovary syndrome phenotypes: a retrospective case series

BackgroundTo explore the efficacy of follitropin delta in ovarian stimulation of patients with the Rotterdam ESHRE/ASRM 2003 phenotypes of polycystic ovarian syndrome (PCOS) using a retrospective case series with an electronic file search in a reproductive medicine clinic.Case presentationSeventy-four patients with PCOS undergoing ovarian stimulation according to the individualized dosing algorithm of follitropin delta for in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI)/oocyte freezing were included. Follitropin delta resulted in a high number of pre-ovulatory follicles at the end of stimulation as expected in patients with PCOS. There was a large number of oocytes retrieved with an acceptable percentage of metaphase II (MII) oocytes. There were no cases of moderate or severe OHSS across all phenotypes.ConclusionFollitropin delta, using the individualized dosing algorithm, appears to be a safe method of ovarian stimulation with a low risk of OHSS in PCOS patients without sacrificing successful stimulation outcomes.

Birthweight and other perinatal outcomes of singletons conceived after assisted reproduction compared to natural conceived singletons in couples with unexplained subfertility: follow-up of two randomized clinical trials.

STUDY QUESTIONDoes assisted reproduction, such as ovarian stimulation and/or laboratory procedures, have impact on perinatal outcomes of singleton live births compared to natural conception in couples with unexplained subfertility?SUMMARY ANSWERCompared to natural conception, singletons born after intrauterine insemination with ovarian stimulation (IUI-OS) had a lower birthweight, while singletons born after IVF had comparable birthweights, in couples with unexplained subfertility.WHAT IS KNOWN ALREADYSingletons conceived by assisted reproduction have different perinatal outcomes such as low birthweight and a higher risk of premature birth than naturally conceived singletons. This might be due to the assisted reproduction, such as laboratory procedures or the ovarian stimulation, or to an intrinsic factor in couples with subfertility.STUDY DESIGN, SIZE, DURATIONWe performed a prospective cohort study using the follow-up data of two randomized clinical trials performed in couples with unexplained subfertility. We evaluated perinatal outcomes of 472 live birth singletons conceived after assisted reproduction or after natural conception within the time horizon of the studies.PARTICIPANTS/MATERIALS, SETTING, METHODSTo assess the possible impact of ovarian stimulation we compared the singletons conceived after IUI with FSH or clomiphene citrate (CC) and IVF in a modified natural cycle (IVF-MNC) or standard IVF with single embryo transfer (IVF-SET) to naturally conceived singletons in the same cohorts. To further look into the possible effect of the laboratory procedures, we put both IUI and IVF groups together into IUI-OS and IVF and compared both to singletons born after natural conception. We only included singletons conceived after fresh embryo transfers. The main outcome was birthweight presented as absolute weight in grams and gestational age- and gender-adjusted percentiles. We calculated differences in birthweight using regression analyses adjusted for maternal age, BMI, smoking, parity, duration of subfertility and child gender.MAIN RESULTS AND THE ROLE OF CHANCEIn total, there were 472 live birth singletons. Of the 472 singleton pregnancies, 209 were conceived after IUI-OS (136 with FSH and 73 with CC as ovarian stimulation), 138 after IVF (50 after IVF-MNC and 88 after IVF-SET) and 125 were conceived naturally.Singletons conceived following IUI-FSH and IUI-CC both had lower birthweights compared to naturally conceived singletons (adjusted difference IUI-FSH −156.3 g, 95% CI −287.9 to −24.7; IUI-CC −160.3 g, 95% CI −316.7 to −3.8). When we compared IVF-MNC and IVF-SET to naturally conceived singletons, no significant difference was found (adjusted difference IVF-MNC 75.8 g, 95% CI −102.0 to 253.7; IVF-SET −10.6 g, 95% CI −159.2 to 138.1). The mean birthweight percentile was only significantly lower in the IUI-FSH group (−7.0 percentile, 95% CI −13.9 to −0.2). The IUI-CC and IVF-SET group had a lower mean percentile and the IVF-MNC group a higher mean percentile, but these groups were not significant different compared to the naturally conceived group (IUI-CC −5.1 percentile, 95% CI −13.3 to 3.0; IVF-MNC 4.4 percentile, 95% CI −4.9 to 13.6; IVF-SET −1.3 percentile, 95% CI −9.1 to 6.4).Looking at the laboratory process that took place, singletons conceived following IUI-OS had lower birthweights than naturally conceived singletons (adjusted difference −157.7 g, 95% CI −277.4 to −38.0). The IVF group had comparable birthweights with the naturally conceived group (adjusted difference 20.9 g, 95% CI −110.8 to 152.6). The mean birthweight percentile was significantly lower in the IUI-OS group compared to the natural group (−6.4 percentile, 95% CI −12.6 to −0.1). The IVF group was comparable (0.7 percentile, 95% CI −6.1 to 7.6).LIMITATIONS, REASONS FOR CAUTIONThe results are limited by the number of cases. The data were collected prospectively alongside the randomized controlled trials, but analyzed as treated.WIDER IMPLICATIONS OF THE FINDINGSOur data suggest IUI in a stimulated cycle may have a negative impact on the birthweight of the child and possibly on pre-eclampsia. Further research should look into the effect of different methods of ovarian stimulation on placenta pathology and pre-eclampsia in couples with unexplained subfertility using naturally conceived singletons in the unexplained population as a reference.STUDY FUNDING/COMPETING INTEREST(S)Both initial trials were supported by a grant from ZonMW, the Dutch Organization for Health Research and Development (INeS 120620027, SUPER 80-83600-98-10192). The INeS study also had a grant from Zorgverzekeraars Nederland, the Dutch association of healthcare insurers (09-003). B.W.J.M. is supported by an NHMRC investigator Grant (GNT1176437) and reports consultancy for ObsEva, Merck Merck KGaA, Guerbet and iGenomix, outside the submitted work. A.H. reports grants from Ferring Pharmaceutical company (the Netherlands), outside the submitted work. F.J.M.B. receives monetary compensation as a member of the external advisory board for Merck Serono (the Netherlands), Ferring Pharmaceutics BV (the Netherlands) and Gedeon Richter (Belgium), he receives personal fees from educational activities for Ferring BV (the Netherlands) and for advisory and consultancy work for Roche and he receives research support grants from Merck Serono and Ferring Pharmaceutics BV, outside the submitted work. The remaining authors have nothing to disclose.TRIAL REGISTRATION NUMBERINeS study Trial NL915 (NTR939); SUPER Trial NL3895 (NTR4057)

Ageing and ovarian stimulation modulate the relative levels of transcript abundance of oocyte DNA repair genes during the germinal vesicle-metaphase II transition in mice.

Oocyte quality and reproductive outcome are negatively affected by advanced maternal age, ovarian stimulation and method of oocyte maturation during assisted reproduction; however, the mechanisms responsible for these associations are not fully understood. The aim of this study was to compare the effects of ageing, ovarian stimulation and in-vitro maturation on the relative levels of transcript abundance of genes associated with DNA repair during the transition of germinal vesicle (GV) to metaphase II (MII) stages of oocyte development. The relative levels of transcript abundance of 90 DNA repair-associated genes was compared in GV-stage and MII-stage oocytes from unstimulated and hormone-stimulated ovaries from young (5-8-week-old) and old (42-45-week-old) C57BL6 mice. Ovarian stimulation was conducted using pregnant mare serum gonadotropin (PMSG) or anti-inhibin serum (AIS). DNA damage response was quantified by immunolabeling of the phosphorylated histone variant H2AX (γH2AX). The relative transcript abundance in DNA repair genes was significantly lower in MII oocytes compared to GV oocytes in young unstimulated and PMSG stimulated but was higher in AIS-stimulated mice. Interestingly, an increase in the relative level of transcript abundance of DNA repair genes was observed in MII oocytes from older mice in unstimulated, PMSG-stimulated and AIS-stimulated mice. Decreased γH2AX levels were found in both GV oocytes (82.9%) and MII oocytes (37.5%) during ageing in both ovarian stimulation types used (PMSG/AIS; p < 0.05). In conclusion, DNA repair relative levels of transcript abundance are altered by maternal age and the method of ovarian stimulation during the GV-MII transition in oocytes.

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.

Different anti-Műllerian hormone (AMH) levels respond to distinct ovarian stimulation methods in assisted reproductive technology (ART): Clues to better ART outcomes.

PurposeWe asked whether the relationship between anti‐Műllerian hormone (AMH) value and the response to ovarian stimulation (OS) might be AMH value‐related and differ for each regimen, aiming at getting clues as to how to choose OS protocols according to AMH levels. We further addressed how AMH value connects with ART outcome.MethodsA total of 1112 women undergoing egg retrieval in ART were included. We adopted four OS protocols, that is, clomiphene, clomiphene + low‐dose gonadotropins (Gns), GnRH (Gn‐releasing hormone) + Gns (short), and GnRH antagonist.ResultsAnti‐Műllerian hormone showed a stronger correlation with egg number compared with age over a wide age range. When patients were stratified into four groups by AMH value (<1, 1‐2, 2‐3, and 3≦ ng/mL), the relationship between AMH and egg number differed among differential OS regimes. The number of eggs rose as AMH and total doses of Gn increased. When analyzed for each AMH group, egg number, but not AMH, was associated with pregnancy rate.ConclusionDifferent AMH levels exhibit characteristic responses to distinct OS regimens. To improve ART outcomes, personalized OS should be selected so as to maximize egg number, which seems to be a more precise variable than AMH for predicting pregnancy.

Association between chromosomal translocation imbalances and aneuploidies in PGT-SR in reciprocal translocation carriers

Introduction Reciprocal translocation carriers are known to be at high risk of conceiving genetically unbalanced embryos, which may result in miscarriage or an affected neonate. Preimplantation genetic testing for chromosomal structural rearrangements (PGT-SR), a method for embryonic chromosomal analysis, can detect not only translocation chromosome imbalance but also aneuploidy via comprehensive chromosomal analysis with whole-genome amplification (WGA), thereby potentially decreasing miscarriage rate. In this study, we aimed to investigate the relationship between chromosomal abnormalities derived from translocation chromosomes and aneuploidies and the frequency of chromosomal abnormalities among stimulation cycles in reciprocal translocation carriers receiving multiple PGT-SR cycles. Material and Method Between 2013 and 2017, we assessed 20 cycles of 8 couples (reciprocal translocation carriers in 5 females and 3 males; mean women's age, 35.1 years) who received 2 or more PGT-SR cycles at our clinic.Ovarian stimulation was primarily controlled, and when chromosomally normal embryos could not be obtained, a different protocol for ovarian stimulation was adapted. All oocytes were fertilized via intracytoplasmic sperm injection (ICSI). All embryos were cultured to the blastocyst stage. Approximately 5-10 trophectoderm (TE) cells were subjected to a biopsy using a laser system. Chromosomal analysis was performed using the microarray-based comparative genomic hybridization method or next-generation sequencing with whole-genome amplification. Result In all 20 cycles, the number of oocytes retrieved was 432 and the number of blastocysts subjected to biopsy was 90. Among 88 analyzable blastocysts, 19 had normal chromosomes (21.6%) and 69 had abnormal chromosomes (78.4%). Fifty-six embryos (81.2%) contained chromosomal imbalances derived from reciprocal translocation chromosomes and 37 embryos (53.6%) had aneuploidy, 24 embryos (34.8%) had both types of abnormalities. The incidence of chromosomal translocation-derived chromosomal imbalance was 60.0% (12/20) for male carriers and 64.7% (44/68) for female carriers, with no significant difference.The incidence of chromosomally normal embryos per cycle was 0–67%. Normal embryos were not obtained in 9 cycles (45%); however, they were obtained at different stimulation cycles. In 9 PGT-SR cycles with three or more embryos of female carriers subjected to biopsy, there was no correlation between the incidence of the abnormality due to chromosome translocation and aneuploidy. Conclusion There is no association between the incidence of translocation chromosome imbalance and aneuploidy. However, approximately 80% of embryos with chromosomal translocation-derived chromosomal imbalance include aneuploidy. The incidence of chromosomal aberrations in embryos has a large difference among the PGT-SR cycles even in the same carrier. In translocation carriers without normal embryos, performing different ovarian stimulation methods enhances the possibility of obtaining normal embryos.

The Four Methods of Ovarian Stimulation in Patients With Polycystic Ovarian Syndrome

The Four Methods of Ovarian Stimulation in Patients With Polycystic Ovarian Syndrome

Ovarian Stimulation inin vitroFertilization

In assisted reproductive technology (ART) treatments, the ovarian stimulation method is important for obtaining many good quality oocytes. The first ovarian stimulation treatments used high stimulation in long and short protocols with gonadotropin releasing hormone (GnRH) agonists. It was formulated to suppress the luteinizing hormone (LH) surge while the follicles are developing. Subsequently, a moderate stimulation with an antagonist was introduced following the development of GnRH antagonists, and low stimulation that inhibits the LH surge with continuous administration of clomiphene citrate. However, cases have been reported occurred in which estrogen replacement therapy was selected to facilitate follicular development by supplementing estrogen in ovarian insufficiency. Otherwise ART cryopreservation technology has also developed. These practices are referred to as oncofertility, and have given rise to new ovarian stimulation methods in infertility treatment. Ovarian stimulation with the random start or double stimulation methods, which are not readily affected by the menstrual cycle, and progestin-primed ovarian stimulation (PPOS) that inhibits the LH surge with a progestogen have come to be performed and are showing good outcomes. As the social and medical backgrounds change, the methods of ovarian stimulation may futher improve in the future.

Comparative Study Between Long Protocol with Antagonist Protocol on IVF Cycle

&lt;p&gt;&lt;strong&gt;Objective&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;Ovarian stimulation is one of important step in In Vitro Fertilization (IVF) program to produce numbers of good oocyte to achieve better pregnancy rate. Various methods of ovarian stimulation have been tried mostly now are long (agonist) and antagonist protocol. The aim of this study is to compare the efficacy and safety of both protocol.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;A retrospective comparative analytical study of all subfertile patients who underwent IVF program from January to December 2011 in Halim Fertility Centre that meets the inclusions and exclusions criteria was done.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;Number of stimulation days in antagonist groups (9.3 &lt;span style="text-decoration: underline;"&gt;+&lt;/span&gt; 1.34 days) was similar with agonist group (9.8 &lt;span style="text-decoration: underline;"&gt;+&lt;/span&gt; 1.57 days). The total dosage of gonadotropin used in antagonist group (1279 &lt;span style="text-decoration: underline;"&gt;+&lt;/span&gt; 805.65) was significantly lower than agonist group (2196.3 &lt;span style="text-decoration: underline;"&gt;+&lt;/span&gt; 931.99). Pregnancy rates between both group was similar (34% in antagonist group vs 36% in agonist group). There was no severe Ovarian Hyperstimulation Syndrome (OHSS) case in antagonist group and there were 5 cases of severe OHSS found in agonist group. There was a significant higher severe OHSS cases in agonist group.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;Ovarian stimulation with agonist and antagonist protocol have similar efficacy in IVF outcome, but antagonist protocol appears to be safer than agonist protocol in term of incidence of severe OHSS.&lt;/p&gt;

Kotter's Eight-Step Change Model: One Centre's Experience for Transition to the GnRH Antagonist Protocol

Background: Gonadotropin releasing hormone (GnRH) agonist cycle was the traditional method of ovarian stimulation at KK Women’s and Children’s Hospital IVF Centre. This long cycle involved many injections, with a poor side effect profile. The GnRH antagonist cycle was introduced in year 2000, with fewer injections per cycle and better side effect profile. Aim: Our department aims to encourage transition from the GnRH agonist cycle to GnRH antagonist cycle, with complete changeover by 2013. Methods: The transformation process was organized according to Kotter’s Eight-Step Change Model from the first half of 2012. Results: This transition led to a five times reduction in the number of oocyte pick-ups on a non-working day. This reduced out-of-hours demands, while maintaining the pregnancy and live birth rates. Incidence of ovarian hyper stimulation syndrome was reduced from 4.0% to 2.2%. By early 2013, 77.2% of ovarian stimulation was done with GnRH antagonist cycles. Conclusion: Kotter’s Eight-Step Change Model was useful to encourage positive transformation. Garnering support from the various users was essential for the transition to GnRH antagonist cycles, which led to enhancement in different dimensions of clinical quality including patient centered processes, effectiveness of treatment and efficiency of service, while maintaining patient’s safety.

Maternal age and ovarian stimulation independently affect oocyte mtDNA copy number and cumulus cell gene expression in bovine clones.

Does maternal ageing and ovarian stimulation alter mitochondrial DNA (mtDNA) copy number and gene expression of oocytes and cumulus cells from a novel bovine model for human IVF? Oocytes collected from females with identical nuclear genetics show decreased mtDNA copy number and increased expression of an endoplasmic reticulum (ER) stress gene with repect to ovarian stimulation, whilst differences in the expression of genes involved in mitochondrial function, antioxidant protection and apoptosis were evident in relation to maternal ageing and the degree of ovarian stimulation in cumulus cells. Oocyte quality declines with advancing maternal age; however, the underlying mechanism, as well as the effects of ovarian stimulation are poorly understood. Human studies investigating these effects are often limited by differences in age and ovarian stimulation regimens within a patient cohort, as well as genetic and environmental variability. A novel bovine cross-sectional maternal age model for human IVF was undertaken. Follicles were aspirated from young (3 years of age; n = 7 females) and old (10 years of age; n = 5 females) Holstein Freisian clones following multiple unstimulated, mild and standard ovarian stimulation cycles. These bovine cloned females were generated by the process of somatic cell nuclear transfer (SCNT) from the same founder and represent a homogeneous population with reduced genetic and environmental variability. Maternal age and ovarian stimulation effects were investigated in relation to mtDNA copy number, and the expression of 19 genes involved in mitochondrial function, antioxidant protection, oocyte-cumulus cell signalling and follicle development in both oocytes and cumulus cells. Young (3 years of age; n = 7 females) and old (10 years of age; n = 5 females) Holstein Freisian bovine clones were maintained as one herd. Stimulation cycles were based on the long GnRH agonist down-regulation regimen used in human fertility clinics. Follicle growth rates, numbers and diameters were monitored by ultrasonography and aspirated when the lead follicles were >14 mm in diameter. Follicle characteristics were analysed using a mixed model procedure. Quantitative PCR (qPCR) was used to determine mtDNA copy number and reverse transcriptase-qPCR (RT-qPCR) was used to measure gene expression in oocytes and cumulus cells. Method of ovarian stimulation (P = 0.04), but not maternal age (P > 0.1), was associated with a lower mtDNA copy number in oocytes. Neither factor affected mtDNA copy number in cumulus cells. In oocytes, maternal age had no effect on gene expression; however, ovarian stimulation in older females increased the expression of GRP78 (P = 0.02), a gene involved in ER stress. In cumulus cells, increasing maternal age was associated with the higher expression of genes involved in mitochondrial maintenance (TXN2 P = 0.008 and TFAM P = 0.03), whereas ovarian stimulation decreased the expression of genes involved in mitochondrial oxidative stress and apoptosis (TXN2 P = 0.002, PRDX3 P = 0.03 and BAX P = 0.03). The low number of oocyte and cumulus cell samples collected from the unstimulated cycles limited the analysis. Fertilization and developmental potential of the oocytes was not assessed because these were used for mtDNA and gene expression quantification. Delineation of the independent effects of maternal age and ovarian stimulation regimen on mtDNA copy number gene expression in oocytes and cumulus cells was enabled by the removal of genetic and environmental variability in this bovine model for human IVF. Therefore, these extend upon previous knowledge and findings provide relevant insights that are applicable for improving human ovarian stimulation regimens. Funding was provided by Fertility Associates and the University of Auckland. J.C.P. is a shareholder of Fertility Associates and M.P.G. received a fellowship from Fertility Associates. The other authors of this manuscript declare no conflict of interest that could be perceived as prejudicing the impartiality of the reported research.

Depot versus daily administration of gonadotrophin-releasing hormone agonist protocols for pituitary down regulation in assisted reproduction cycles

Gonadotrophin-releasing hormone agonist (GnRHa) is commonly used to switch off (down regulate) the pituitary gland and thus suppress ovarian activity in women undergoing in vitro fertilisation (IVF). Other fertility drugs (gonadotrophins) are then used to stimulate ovulation in a controlled manner. Among the various types of pituitary down regulation protocols in use, the long protocol achieves the best clinical pregnancy rate. The long protocol requires GnRHa administration until suppression of ovarian activity occurs, within approximately 14 days. GnRHa can be used either as daily low-dose injections or through a single injection containing higher doses of the drug (depot). It is unclear which of these two forms of administration is best, and whether single depot administration may require higher doses of gonadotrophins. To compare the effectiveness and safety of a single depot dose of GHRHa versus daily GnRHa doses in women undergoing IVF. We searched the following databases: Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched July 2012), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 7), MEDLINE (1966 to July 2012), EMBASE (1980 to July 2012) and LILACS (1982 to July 2012). We also screened the reference lists of articles. We included RCTs comparing depot and daily administration of GnRHa for long protocols in IVF treatment cycles in couples with any cause of infertility, using various methods of ovarian stimulation. The primary review outcomes were live birth or ongoing pregnancy, clinical pregnancy and ovarian hyperstimulation syndrome (OHSS). Other outcomes included number of oocytes retrieved, miscarriage, multiple pregnancy, number of gonadotrophin (FSH) units used for ovarian stimulation, duration of gonadotrophin treatment, cost and patient convenience. Two review authors independently selected studies, extracted data and assessed study quality. For dichotomous outcomes, we calculated odds ratios (ORs) and 95% confidence intervals (CIs) per woman randomised. Where appropriate, we pooled studies. Sixteen studies were eligible for inclusion (n = 1811 participants), 12 (n = 1366 participants) of which were suitable for meta-analysis. No significant heterogeneity was detected.There were no significant differences between depot GnRHa and daily GnRHa in live birth/ongoing pregnancy rates (OR 0.95, 95% CI 0.70 to 1.31, seven studies, 873 women), but substantial differences could not be ruled out. Thus for a woman with a 24% chance of achieving a live birth or ongoing pregnancy using daily GnRHa injections, the corresponding chance using GnRHa depot would be between 18% and 29%.There was no significant difference between the groups in clinical pregnancy rate (OR 0.96, 95% CI 0.75 to 1.23, 11 studies, 1259 women). For a woman with a 30% chance of achieving clinical pregnancy using daily GnRHa injections, the corresponding chance using GnRHa depot would be between 25% and 35%.There was no significant difference between the groups in the rate of severe OHSS (OR 0.84, 95% CI 0.29 to 2.42, five studies, 570 women), but substantial differences could not be ruled out. For a woman with a 3% chance of severe OHSS using daily GnRHa injections, the corresponding risk using GnRHa depot would be between 1% and 6%.Compared to women using daily GnRHa, those on depot administration required significantly more gonadotrophin units for ovarian stimulation (standardised mean difference (SMD) 0.26, 95% CI 0.08 to 0.43, 11 studies, 1143 women) and a significantly longer duration of gonadotrophin use (mean difference (MD) 0.65, 95% CI 0.46 to 0.84, 10 studies, 1033 women).Study quality was unclear due to poor reporting. Only four studies reported live births as an outcome and only five described adequate methods for concealment of allocation. We found no evidence of a significant difference between depot and daily GnRHa use for pituitary down regulation in IVF cycles using the long protocol, but substantial differences could not be ruled out. Since depot GnRHa requires more gonadotrophins and a longer duration of use, it may increase the overall costs of IVF treatment.

Factors predicting the outcome of intrauterine insemination

Background: Intrauterine insemination (IUI) is a frequently indicated therapeutic modality in infertility and considered to be of low to moderate complexity before the application of more sophisticated assisted reproductive technologies (ART). It is simple and inexpensive treatment in which processed and concentrated motile sperm are placed directly into uterine cavity. IUI is used together with various controlled ovarian hyperstimulation (COH) protocols for many indications such as male infertility, ovulatory disorders, endometriosis and unexplained infertility. Aim of study: Is to identify the important prognostic variables contributing to the successful outcome. Patients and methods: A prospective study was carried out at Assisted Conception Unit of Basra Medical College, A total of 203 cycles were analyzed to identify prognostic factors regarding treatment outcome. The variables selected for analysis were female age, duration and etiology of infertility, sperm parameters, number of preovulatory follicles, and number of previous treatment cycles and the method of COH. Results: The overall pregnancy rate per cycle was 9.3% (19/203). Of 19 pregnancies, 68.4% resulted in live birth, 26.3% in spontaneous abortion, and 5.3% were ectopic pregnancy. The multiple pregnancy rate was 15.8 % (3 twin pregnancies). Three significant variables for successful outcome were total motile sperm count (>10x106), the method of ovarian stimulation (use of r-FSH alone being superior to Clomiphen Citrate (CC) with r-FSH and CC alone), and multifollicular response. There was a tendency to a higher pregnancy rate in women 10x106), controlled ovarian hyperstimulation (COH) with r-FSH and multifollicular response are valuable predictors for pregnancy in COH-IUI cycle.

Micro-dose flare-up gonadotrophin-releasing hormone (GnRH) agonist vs. flexible gonadotrophin-releasing hormone (GnRH) antagonist protocol in patient with poor ovarian reserve

To compare the efficacy of two methods of ovarian stimulation, namely micro-dose flare-up gonadotrophin-releasing hormone (GnRH) agonist protocol and flexible gonadotrophin-releasing hormone (GnRH) antagonist protocol in patients with poor ovarian reserve. A prospective, randomized, double blind clinical trial. Department of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University, Infertility Clinic, Ismailia, Egypt, Private Center, Cairo, Egypt, December 2006–May 2008. Fifty-nine patients with poor ovarian responses based on the following criteria ovarian volume <3 ml (26) . Low antral follicular count (AFC) <6 27 , 28 . Cycle (day 3) FSH >8 IU/l (29) undergoing IVF/ICSI treatment. Exclusion criteria: (1) any other cause of infertility other than poor ovarian reserve; (2) refusal of the patient to be enrolled to the study. All women were prospectively randomized into two groups by computer-assisted randomization. The patients in group 1 were stimulated according to the micro-dose flare-up protocol ( n = 30), while the patients in group 2 were stimulated according to flexible antagonist protocol ( n = 29). The mean number of oocytes retrieved was the primary outcome measure, number of mature oocytes retrieved, number of fertilized oocytes, number of embryos transferred, stimulation duration (days), total dose of gonadotrophin IU, estradiol concentration on the day of hCG administration, fertilization rate, implantation rate, ongoing pregnancy rate were secondary outcome measures, cancellation rate. The use of flexible GnRH antagonist protocol ended with significantly less gonadotrophin requirements (2831.9 ± 623.02 vs. 3187.5 ± 704.04; p = 0.04) and a shorter duration of stimulation (9.6 ± 2.02 vs. 10.8 ± 2.4 days; p = 0.04). The fertilization rate (77.3% vs. 68.5), implantation rate (12.2% vs. 8.9%), and ongoing pregnancy rate (20.8% vs. 12.5%) were higher in the antagonist group but did not achieve statistical significance. The cancellation rate was higher in the agonist group (20% vs. 17.2%) but the difference was not statistically significant. The numbers of oocytes retrieved, mature oocytes, fertilized oocytes, embryo transfer, and the estradiol concentration on the day of hCG were not significantly different between the two groups compared. The role of flexile GnRH antagonist in women with poor ovarian reserves appear to be promising and further randomized clinical trials are needed.

Randomized comparison of different ovarian stimulation regimens for assisted reproductive technology in baboons (Papio anubis)

To compare different methods of ovarian stimulation (OS) for assisted reproductive technology in baboons. Prospective randomized study. Institute of primate research. Baboons (n = 10) were randomized into two groups (of five animals each) during three different cycles to compare six protocols of OS. Cycle 1: clomiphene citrate (CC) alone (group CC) versus CC and GnRH agonist (group CC-Ag); cycle 2: recombinant gonadotropins (GON) without GnRH agonist (group GON) versus GON and depot GnRH agonist (group GON-AgDepo-1); cycle 3: GON and depot GnRH agonist (group GON-AgDepo-2) versus GON and daily GnRH agonist in a classic long protocol (group GON-Ag). Oocyte aspiration was performed 34-36 hours after injecting 5,000 IU rhCG, followed by fertilization via intracytoplasmic sperm injection (ICSI). Number and quality of oocytes retrieved and their fertilization rate. More metaphase II (MII) oocytes were retrieved using the GON-AgDepo-1 (n = 12; 64% MII), GON-AgDepo-2 (n = 9; 79% MII), GON-Ag (n = 16; 88% MII), and GON (n = 6; 59% MII) protocols compared with the CC (n = 9; 15% MII) and CC-Ag (n = 14; 20% MII) protocols. Fertilization by ICSI varied between 43% and 71%. In baboons, long and depot protocols yield similar numbers of MII oocytes; however, depot protocol may be preferable because only one injection of GnRH agonist is needed.

Women with cancer undergoing ART for fertility preservation: a cohort study of their response to exogenous gonadotropins

Cancer patients produce similar numbers of oocytes after ovarian hyperstimulation compared with age-matched infertile controls, suggesting that malignancy does not adversely affect ovarian response.