Clinical evaluation of three different gonadotrophin-releasing hormone analogues in an IVF programme: a prospective study.

The efficacy and safety of short acting buserelin and nafarelin intranasal spray were compared to long acting leuprorelin depot intramuscular or subcutaneous injection in this prospective study of 157 women undergoing controlled ovarian hyperstimulation (COH) for in-vitro fertilisation (IVF). Patients were allocated to three groups to receive buserelin 150 microg nasal spray three times daily (Group B), nafarelin nasal spray 400 microg twice daily (Group N), or leuprorelin depot 3.75 mg once by intramuscular or subcutaneous injection (Group L) for pituitary desensitisation prior to commencing COH with human menopausal gonadotrophins (hMG) according to the Centre's protocol. The mean (+/-S.D.) age (years) (32.6+/-3.8: Group B, 32.1+/-3.3: Group N versus 32.1+/-3.3: Group L); mean (+/-S.D.) total dosage of hMG (ampoules) (37.5+/-16.1: Group B, 39.8+/-14.2: Group N versus 41.9+/-12.6: Group L) and mean daily dosage of hMG (ampoules) (3.1: Group B, 2.8: Group N versus 3.0: Group L) seen were not statistically significantly different. The duration between starting the different gonadotrophin-releasing hormone (GnRHa) and the beginning of the next menstrual period was also not seen to be statistically significantly different between the three groups (Group B: 10+/-5.5, Group N: 9.1+/-4.1 versus Group L: 8.2+/-3, days). The number of abandoned cycles was higher in Group L (17% versus 11.8%: Group B and 11.3%: Group N) but this difference did not reach statistical significance. The clinical pregnancy rates per oocyte retrieval and per embryo transfer procedure were respectively, 31.1, 35% in Group B, 12.8, 14% in Group N versus 20.5, 23.7 in Group L and were not seen to be statistically significantly different even when ongoing pregnancy rates were compared. Apart from a statistically significantly greater incidence of allergic nasal reactions in the nafarelin group (P=0.001), all other side-effects were not shown to be statistically significantly different between the three groups. We conclude that a single dose of leuprorelin depot can be considered to be as an equally effective alternative to multiple doses of buserelin or nafarelin for pituitary desensitisation in women undergoing COH for IVF.

Early pregnancy is elusive and robust.

We describe a live birth occurring following bilateral ovarian diathermy, hysteroscopy and dye test in women with clomiphene citrate resistant polycystic ovarian syndrome performed inadvertently during early pregnancy. A woman with polycystic ovarian syndrome resistant to Clomiphene citrate had bilateral laparoscopic ovarian diathermy performed inadvertently during early pregnancy. The patient was treated by Clomiphene citrate for 12 cycles then she had bilateral laparoscopic ovarian diathermy and hysteroscopy and dye test. Pelvic ultrasound examination, serum beta hCG, serum LH, FSH, Prolactin, T, SHBG, DHAS and serum E2 level. Successful outcome of pregnancy following bilateral laparoscopic ovarian diathermy and hysteroscopy and dye test inadvertently performed during early pregnancy. That all women scheduled for elective pelvic surgery should be advised to use effective contraception or avoid unprotected sexual intercourse in the preceding month as well as having an hCG test prior to surgery to exclude pregnancy.

Does pretreatment with progestogen or oral contraceptive pills in low responders followed by the GnRHa flare protocol improve the outcome of IVF-ET?

PURPOSE: Women undergoing in vitro fertilization with low ovarian reserve and poor response to controlled ovarian hyperstimulation (COH) present a management dilemma. In a retrospective observational study, we compared the pretreatment use of the gestogen medroxyprogesterone acetate (10 mg twice daily from day 15 of the cycle for a minimum of 2 weeks) with an oral contraceptive pill (one tablet daily from day 4 of the cycle for a minimum of 3 weeks). METHODS: The criteria for inclusion in the study included one or more of the following: abandoned cycles due to poor response, fewer than four oocytes retrieved following a standard COH protocol, age > 39 years, and elevated basal serum follicle-stimulating hormone (FSH). Thirty-eight women received pretreatment with gestogen, and a similar number of women received pretreatment with the pill. The flare protocol was used in all treatment cycles combined with an individualized dose of human menopausal gonadotropin (hMG) (4-8 ampoules/day of 75 units FSH/ampoule) depending on previous response, age, and early follicular serum FSH level. Both groups were similar in mean age, duration of infertility, early follicular FSH levels, and the distribution of various aetiologies. RESULTS: Twenty-nine cycles were abandoned before oocyte retrieval, 15 (39.5%) in the pill group and 14 (36.8%) in the gestogen group, because of an inadequate ovarian response. The mean (+/- SD) number of ampoules (75 IU FSH/ampoule) of hMG used per cycle was similar in the pill and gestogen groups (59.7 +/- 19.3 vs. 70.2 +/- 29.4, respectively). There also was no difference seen in the numbers of oocytes retrieved (4.4 +/- 2.3 vs. 4.2 +/- 2.5), total number of embryos (2.5 +/- 2.4 vs. 2.2 +/- 1.1), or the number of embryos transferred (1.8 +/- 1.2 vs. 2.1 +/- 1.0) in the pill and gestogen groups, respectively. One pregnancy in each group resulted following embryo transfer in 22 women in the pill group and in 24 women in the gestogen group. CONCLUSIONS: We conclude that pre-IVF treatment with oral contraceptive pill or gestogen combined with the flare protocol in women at high risk of or with a history of poor ovarian response, as defined in this study, did not appear to result in an improvement in outcome of IVF-embryo transfer.