Dual trigger with gonadotropin releasing hormone agonist and human chorionic gonadotropin significantly improves live birth rate for women with diminished ovarian reserve.

BACKGROUND: Diminished ovarian reserve (DOR) remains one of the greatest obstacles affecting the chance of a successful live birth after fertility treatment. The present study was set to investigate whether using a "dual trigger" consisted of human chorionic gonadotropin (hCG) plus gonadotropin releasing hormone agonist (GnRH-a) for final oocyte maturation could improve the IVF cycle outcomes for patients with diminished ovarian reserve. METHODS: A total of 427 completed GnRH-antagonist downregulated IVF cycles with fresh embryo transfer (ET) were included in this retrospective analysis. DOR was defined as antral follicle count ≤5 and serum anti-Müllerian hormone level ≤ 1.1 ng/mL. The control group (n = 130) used a 6500 IU of recombinant hCG for trigger, and the study group (n = 297) used 0.2 mg of triptorelin plus 6500 IU of recombinant hCG for trigger. RESULTS: The dual-trigger group had significantly higher oocyte fertilization rate (73.1% vs. 58.6%), clinical pregnancy rate (33.0% vs. 20.7%) and live birth rate (26.9% vs. 14.5%) when compared to the hCG trigger group. In addition, the abortion rate (17.4% vs. 37.0%) and embryo transfer cancellation rate (6.1% vs. 15.4%) were both significantly lower in the dual trigger group. The primary outcome measure was the live birth rate per oocyte retrieval cycle. Secondary outcome measures were embryo transfer cancellation rate, clinical pregnancy rate, implantation rate, chemical pregnancy rate and abortion rate per oocyte retrieval cycle. CONCLUSIONS: Dual triggering the final oocyte maturation with GnRH-a and standard dose of hCG can significantly improve the live birth rate, clinical pregnancy rate, and fertilization rate in women with diminished ovarian reserve undergoing GnRH antagonist down-regulated IVF-ICSI cycles.

Live birth after perimortem cesarean delivery in a 36-year-old out-of-hospital cardiac arrest nulliparous woman.

OBJECTIVE: The aim of this study is to share a valuable experience of perimortem Cesarean delivery (PMCD) when no signs of spontaneous circulation were detected after 4 min of resuscitation. The time interval between maternal cardiac arrest and neonatal delivery was evaluated and reviewed. CASE REPORT: We present the case of an out-of-hospital cardiac arrest (OHCA) in a nulliparous woman who survived a car accident with only seatbelt injuries. The term infant was delivered by PMCD at our emergency department at least 43 min after maternal cardiac arrest. The mother only had concussion and was healthy at the time of discharge. The infant survived but had moderate neurological growth impairment (cerebral palsy) at the age of 7 months. CONCLUSION: Contrary to previous studies and case reports, maternal and neonatal outcomes seem to be better when performing PMCD within 10 min. Multidisciplinary teamwork is the key for optimal outcomes in such situations.

Early blastulation of day 4 embryo correlates with the increased euploid rate of preimplantation genetic screening cycles.

OBJECTIVE: It is known that embryos with faster growing potential, especially in blastocyst development, correlate with the increased euploid rate. Our study investigated the preimplantation genetic screening cycle to analyze the correlation between early blastulation (EB) on day 4 embryo and the euploid rate. MATERIALS AND METHODS: This is a retrospective study examining 273 biopsied blastocysts after preimplantation genetic screening obtained from 54 patients from March 2013 to March 2017. Of the 273 biopsied embryos, 81 had early blastulation on day 4 and were classified as the EB (+) group, while the other 192 had no early blastulation and were classified as the EB (-) group. Euploid rates were compared between the two groups. A total of 34 single euploid embryos were transferred, with 14 from the EB (+) group and 20 from the EB (-) group. Clinical pregnancy was compared between the groups. RESULTS: There is a statistically significant increase in the euploid rate in the EB (+) group (49.4% vs. 34.4%, p = 0.02). The clinical pregnancy rate was also increased in the single euploid embryo transfer group with early blastulation, but did not reach statistical significance (71.4% vs. 50.0%, p = 0.211). CONCLUSIONS: Early blastulation of day 4 embryo correlates significantly with the euploid rate. Early blastulation of day 4 embryo may serve as a potential aid for embryo selection for transfer in preimplantation genetic screening cycles.

Early blastulation (EB) of day 4 embryo is predictive of outcomes in single embryo transfer (SET) cycles.

OBJECTIVE: The aim of this study was to assess whether the early blastulation (EB) of day 4 embryo is a useful predictor for outcomes in fresh elective single embryo transfer (eSET) cycles. MATERIALS AND METHODS: We retrospectively enrolled patients undergoing fresh SET cycles in our hospital from April 2014 to September 2016 and met with the following criteria: 1) age <38 years, 2) first IVF/ICSI cycle, 3) at least two blastocysts with morphological grading better than or equal to 4BB. RESULTS: A total of 81 patients were included. Of whom, 55 patients (68%) had undergone eSET with embryos that had early blastulation on day 4 while the other 26 patients had had no EB. Early blastulation has shown a higher rate of good blastocyst (84.3% vs. 60.5%, p < 0.0001). The clinical pregnancy rate of EB group was significantly higher than that of non-EB group (56.4% vs. 27.0%, p = 0.013). There is also a tendency in EB group to have a lower abortion rate (3.23% vs. 28.6%, p = 0.081). CONCLUSIONS: EB on day 4 is a useful predictor of the quality of the following embryos (i.e. day 5 embryo). It is a simple tool in selecting the best embryo to get a higher pregnancy rate in fresh eSET cycles. TRIAL REGISTRATION: This study was supplementally registered by the MacKay Memorial Hospital Institutional Review Board on April 18, 2017 (registration No. 17MMHIS039e).

Day 4 good morula embryo transfer provided compatible live birth rate with day 5 blastocyst embryo in fresh IVF/ET cycles.

OBJECTIVE: Embryo transfers during cleavage stage (day 2 or day 3) and blastocyst stages (day 5 or day 6) are common in current daily practice in fresh IVF/ET cycles. Data regarding transferring day 4 embryos, morula/compact stage, is still restricted and the grading system is also inconsistent, as between IVF clinics. This study provided a new detailed classification system for morula/compact stage embryos and compared successes rates between day 4 and day 5 ET. MATERIALS AND METHODS: This was a retrospective study. A review of medical records from January 1st, 2013, to December 31st 2015, performed for all conventional insemination and ICSI cycles with a GnRH-antagonist protocol at the Infertility Division of MacKay Memorial Hospital in Taipei City, Taiwan. RESULTS: There were 427 cycles included in our study, 107 in study group (day 4 MET) and 320 in control group (day 5 BET). Pregnancy rates and live birth rate were compatible, as between morula embryo transfer (MET) and blastocyst embryo transfer (BET). The implantation rate (36.3% vs. 39.6%, respectively, p = 0.500), clinical pregnancy rate (49.5% vs. 51.9%, respectively, p = 0.737), and live birth rate (42.1% vs. 45.6%, respectively, p = 0.574) were statistically insignificant between groups. The term birth rate was statistically higher in the MET group than in the BET group (95.7% vs. 79.5%, respectively, p = 0.006). When the clinical outcomes between day 4 good MET and day 5 good BET were compared, the results were compatible. The implantation rate (48.8% vs. 41.1%, respectively, p = 0.335), clinical pregnancy rate (55.0% vs. 53.2%, respectively, p = 0.867), and live birth rate (47.5% vs. 47.1%, respectively, p = 1.000) showed no significant difference. The term birth rate was also higher in day 4 good MET group than in day 5 good BET group (100% vs. 78.3%, respectively, p = 0.025). CONCLUSION: In this study, we performed day 4 MET avoid BET on Sunday. The grading system we provided was more detailed for embryo selection and it was easier to remember. Our data showed that morula embryo transfer might be a flexible, easier and applicable method for embryo transfer in daily routine.