Can letrozole plus HMG protocol improve pregnancy outcomes in frozen-thawed embryo transfer? an RCT

Background: There are different methods in endometrial preparation for frozen-thawed embryo transfer [FET]

Objective: The purpose of this study was to compare the live birth rate in the artificial FET protocol [estradiol/ progesterone with GnRH-agonist] with stimulated cycle FET protocol [letrozole plus HMG]

Materials and Methods: This randomized clinical trial included 100 women [18-42 years] randomly assigned to two groups based on Bernoulli distribution. Group I received GnRH agonist [Bucerelin, 500 micro g subcutaneously] from the previous midlutea lcycle, Then estradiol valerat [2 mg/ daily orally] was started on the second day and was increased until the observation of 8mm endometrial thickness. Finally progesterone [Cyclogest, 800 mg, vaginally] was started. Group II received letrozole on the second day of the cycle for five days, then HMG 75 IU was injected on the7P[th] day. After observing [18 mm folliclhCG10000 IU was injected for ovulation induction. Trans cervical embryo transfer was performed in two groups. The main outcome was the live birth rate. The rate of live birth, implantation, chemical, and clinical pregnancy, abortion, cancellation and endometrial thickness were compared between two groups

Results: Implantation rate was significantly higher in group I. Live birth rate was slightly increased in group I without significant difference [30% vs. 26%]. The rate of chemical and clinical pregnancy was similar in two groups. The abortion rate was lower in letrozole protocol but the difference was not statistically significant. The mean endometrial thickness was not different between two groups

Conclusion: Letrozole plus HMG method cannot improve pregnancy outcomes in frozen-thawed embryo transfer but it has only one injection compare to daily injections in artificial method

Prediction of assisted reproductive technique outcome in elevated early follicular phase follicle stimulating hormone with Mullerian inhibiting substance level

Detection of best predictor of ovarian reserve in patients with temporarily or consistently elevated early follicular phase serum levels of FSH is one of the most important goals in assisted reproductive technique [ART]. To evaluate whether high level of anti-mullerian hormone level is related to success of ART in patients with temporarily or consistently elevated early follicular phase serum levels of FSH. Sixty three women underwent intracytoplasmic sperm injection [ICSI] with GnRH-agonist long protocol or intrauterine insemination [IUI] in a prospective cohort study. FSH, inhibin B and anti-Mullerian hormone [AMH] levels were measured in these women whom were divided to three groups [persistently elevated FSH, variably elevated FSH and, normal FSH level]. Basal characteristics, stimulation parameters, and pregnancy occurrence were evaluated. AMH was significantly higher in women with persistently elevated early follicular phase FSH achieving pregnancy. Women with normal FSH did not have significant difference in AMH level between conceived and non conceived cycles. Women with only one elevated early follicular phase FSH achieving pregnancy did not have significant difference in AMH level with non pregnant women. Response to gonadotropin stimulation, recommendation to oocyte donation significantly differed between the groups. This study has demonstrated that relatively young women with persistently or intermittently elevated day 3 FSH levels have diminished ovarian reserve and lower ART success. However, in women whose FSH levels were constantly elevated, AMH [not inhibin B] concentrations were significantly higher in ART cycles resulting in pregnancy. Therefore, AMH level is a good predictor of ART outcome in patients with elevated early follicular phase serum levels of FSH

Anti-mullerian hormone as a predictive factor in assisted reproductive technique of polycystic ovary syndrome patients

This study aimed to assess the relationship between the serum levels of anti-mullerian hormone [AMH] and other hormonal markers and results of assisted reproductive techniques [ART] in polycystic ovary syndrome [PCOS] patients. This cohort study was conducted on 60 PCOS patients who were candidates for assisted reproductive techniques. In all patients the serum levels of AMH, follicle stimulating hormone [FSH] and luteinizing hormone [LH], estradiol [E2], free testosterone [fT], testosterone [T] and inhibin B were measured in the 3rd day of menstrual cycle. The relationship between serum level of measured hormonal markers with retrieved oocytes, mature oocytes, the number of transferred fetus and pregnancy rate were assessed. The cut-off value for the serum level of AMH and retrieved oocytes were determined. There was a significant direct correlation between the serum mullerian inhibiting substance [MIS] level with number of total picked up oocytes [r=0.412], mature oocytes [r=0.472] and embryo transfer [r=0.291]. There was a linear and significant correlation between inhibin B and fertilization [r=0.283] Cut-off point for AMH level according to presence or absence of pregnancy was 4.8 ng/ml and it was not statistically significant [P=0.655]. Area under curve [AUC] was 0.543. Cut-off point for MIS according to picked up oocytes was 2.7 ng/ml with area under the curve [ROC curve] of 0.724 [CI=0.591-0.831] [P=0.002]. Patients with PCOS who had AMH more than 2.7 ng/ml, the number of retrieved oocytes [6 or more] was higher than MIS/AMH<2.7 ng/ml [P=0.002]. As a marker of ovarian responsiveness to controlled ovarian hyperstimulation [COH] and despite a small sample size of our study, it is revealed that pretreatment MIS/AMH is highly associated with the number of mature oocytes retrieved during COH in PCOS women

effectiveness of cabergoline for the prevention of ovarian hyperstimulation syndrome

Type 2 receptors for vascular endothelial growth factor are believed to be involved in the pathophysiology of ovarian hyper-stimulation syndrome [OHSS]. The objective of this study was to examine the preventive effects of cabergoline on OHSS and its complications. The study is a non randomized clinical trial conducted in 2006-2008 on 75 patients, which were at risk of OHSS and underwent assisted reproductive techniques. The diagnosis and severity of OHSS were determined using standard criteria. The study included an intervention and a control group. The intervention group comprised of 50 women at risk of OHSS, who were treated with cabergoline [1mg every other day for 8 days] commencing from the day of ovum pick up. The control group comprised of 35 historical cases, which were similar to the case group. The latter group did not receive cabergoline, and their OHSS, if occurred, were managed conservatively after hospital admission. The rates of OHSS, baseline characteristics, ovarian stimulation parameters, and pregnancy occurrence were compared. There was no significant difference between baseline characteristics or ovarian stimulation parameters from the two groups. The incidence of OHSS in the cabergoline-treated group, was significant [P=0.01] lower than that in the control group [12% vs 36%]. Embryo freezing was significantly [P=0.001] lower in the cabergoline group. The findings of the study indicate that cabergoline reduces the incidence of OHSS, and is not associated with adverse effects on pregnancy

Relationship between anti-mullerian hormone and assisted reproductive technique outcome in patients with polycystic ovary syndrome

Anti-mullerian hormone [AMH] levels may represent the ovarian follicular pool and could be a useful marker of ovarian reserve. The clinical application of AMH measurement has been proposed in the prediction of quantitative and qualitative aspects in assisted reproductive technologies. This study aimed to assess the relationship between the serum levels of AMH and results of assisted reproductive technique [ART] outcome in polycystic ovary syndrome [PCOS] patients versus control group. This cohort study was conducted on 61 [PCOS] patients and 28 patients without PCOS [controls] candidates for assisted reproductive technique. Serum levels of AMH were measured on the 3[rd] day of menstrual cycle and all the patients underwent controlled ovarian hyper stimulation and ART. The relationship between AMH serum level with retrieved oocytes, mature oocytes and pregnancy rate were assessed. There was significant correlation between the AMH level with number of total retrieved oocytes and mature oocytes in patients with PCOS and controls [p=0.001]. In PCOS and control groups AMH level in pregnant patients was higher, but it was not statically significant [p=0.65, p=0.46, respectively]. The major outcome of the study [pregnancy] did not differ significantly between two groups. This study revealed that AMH level was higher in pregnant patients undergoing ART; but AMH may not be an accurate predictor for pregnancy in PCOS patients