Fresh versus frozen embryo transfer after gonadotropin-releasing hormone agonist trigger in gonadotropin-releasing hormone antagonist cycles among high responder women: A randomized, multi-center study.

Background: The use of embryo cryopreservation excludes the possible detrimental effects of ovarian stimulation on the endometrium, and higher reproductive outcomes following this policy have been reported. Moreover, gonadotropin-releasing hormone agonist trigger in gonadotropin-releasing hormone (GnRH) antagonist cycles as a substitute for standard human chorionic gonadotropin trigger, minimizes the risk of ovarian hyperstimulation syndrome (OHSS) in fresh as well as frozen embryo transfer cycles (FET). Objective: To compare the reproductive outcomes and risk of OHSS in fresh vs frozen embryo transfer in high responder patients, undergoing in vitro fertilization triggered with a bolus of GnRH agonist. Materials and Methods: In this randomized, multi-centre study, 121 women undergoing FET and 119 women undergoing fresh ET were investigated as regards clinical pregnancy as the primary outcome and the chemical pregnancy, live birth, OHSS development, and perinatal data as secondary outcomes. Results: There were no significant differences between FET and fresh groups regarding chemical (46.4% vs. 40.2%, p=0.352), clinical (35.8% vs. 38.3%, p=0.699), and ongoing (30.3% vs. 32.7%, p=0.700) pregnancy rates, also live birth (30.3% vs. 29.9%, p=0.953), perinatal outcomes, and OHSS development (35.6% vs. 42.9%, p=0.337). No woman developed severe OHSS and no one required admission to hospital. Conclusion: Our findings suggest that GnRHa trigger followed by fresh transfer with modified luteal phase support in terms of a small human chorionic gonadotropin bolus is a good strategy to secure good live birth rates and a low risk of clinically relevant OHSS development in in vitro fertilization patients at risk of OHSS.

GnRH antagonist/letrozole versus microdose GnRH agonist flare protocol in poor responders undergoing in vitro fertilization.

OBJECTIVE: To evaluate and compare the efficacy of microdose gonadotropin-releasing hormone (GnRH) agonist flare (MF) and GnRH antagonist/letrozole protocols in poor responders undergoing in vitro fertilization. MATERIALS AND METHODS: A total of 94 poorly responding patients were randomized in an ovarian stimulation protocol with a MF, or a letrozole and high dose follicle-stimulating hormone/human menopausal gonadotropin and flexible GnRH antagonist protocol. RESULTS: There was no significant difference in mean age, body mass index, basal serum follicle stimulating hormone and estradiol levels, duration of infertility, distribution of etiology of infertility, and the number of previously failed in vitro fertilization cycles. The days of stimulation, mean gonadotropin dose, the number of mature follicles, and oocytes retrieved and metaphase II oocytes retrieved, serum estradiol level on the day of human chorionic gonadotropin administration, and the percentage of top and good quality embryos were significantly higher in the MF group. The endometrial thickness, fertilization rate, and the number of embryos transferred were similar in both groups. The implantation and clinical pregnancy rates were higher in the MF group and the total cancellation rate was higher in the GnRH antagonist/letrozole group, but these findings were not statistically significant. CONCLUSION: The addition of letrozole to the GnRH antagonist for poor responders does not improve the outcome of assisted reproductive technology cycles. The MF protocol remains the most appropriate protocol in poor responders.

Can fresh embryo transfers be replaced by cryopreserved-thawed embryo transfers in assisted reproductive cycles? A randomized controlled trial.

PURPOSE: Controlled ovarian hyperstimulation has been shown to advance endometrial maturation and adversely affects implantation in ART. It has been reported that there is a better embryo-endometrium synchrony in frozen-thawed embryo transfer cycles than fresh embryo transfer cycles. The objective of this study was to compare ongoing pregnancy rates between fresh ET and FET cycles. METHODS: In an open prospective, controlled study, the patients who were classified as high responders, were randomized to either fresh ET or FET. The embryos in FET group were cryopreserved with vitrification by Cryotop method. RESULTS: A total of 374 patients were included, 187 of which were randomized to FET and 187 to fresh ET. There were 39% (n = 73) ongoing pregnancy in FET group compared with 27.8% (n = 52) in fresh ET group[odds ratio = 1.66;95% confidence interval = 1.07-2.56; p = 0.02]. CONCLUSIONS: FETs can be performed instead of fresh ETs to improve the outcome of ART in highly selected patients.

Comparison of mild stimulation and conventional stimulation in ART outcome.

PURPOSE: To provide a treatment for particular condition that is the most effective treatment with the least risk and cost for the patient we compared the efficacy of using clomiphene 100 mg + delayed low dose gonadotropin + flexible GnRH antagonist administration for ovarian stimulation protocol and GnRH agonist + gonadotropin for stimulation protocol in IVF outcome. METHODS: Clinical outcome of 243 women with regularly menstruation who were candidate for IVF. They had undergone stimulation with GnRH agonist and gonadotropin (group A) or clomiphene citrate, gonadotropin and GnRH antagonist (group B). Main outcome was ongoing pregnancy. RESULTS: There were no significant difference in mean age, cause of infertility, basal FSH, BMI, duration of infertility, endometrial thickness on the day HCG administration in two groups. The number of recovered oocytes, obtained embryos, transferred embryos, peak of estradiol on the day HCG administration and OHSS were significantly higher in group A. Significantly more patients in control group had embryos for cryopreservation. There were no significant difference in clinical pregnancy rate and ongoing pregnancy rate between two groups. CONCLUSION: Clomiphene + delayed low dose gonadotropin + flexible GnRH - antagonist stimulation is an acceptable alternative protocol for IVF in patients with regularly menstruation.

Local injury to the endometrium on the day of oocyte retrieval has a negative impact on implantation in assisted reproductive cycles: a randomized controlled trial.

PURPOSE: To evaluate the effect of local injury to the endometrium on the day of oocyte retrieval on implantation and pregnancy rates in assisted reproductive cycles. METHODS: In a prospective controlled trial, a total of 156 patients, <38 years old, in their first in vitro fertilization (IVF) cycle were randomized. In 77 patients, two small endometrial samples from anterior and posterior walls of uterus were obtained with a Novak curette on the day of oocyte retrieval and in 79 patients no intervention was performed. RESULTS: The experimental and control patients were matched regarding women's age, body mass index, basal FSH, duration and etiology of infertility, treatment protocol, number of retrieved oocyte, endometrial thickness, percentage of intracytoplasmic sperm injection performance, fertilization rate, the percentage of patients with good and top quality embryos, and the number of embryos transferred. The implantation rate (7.9 vs. 22.9%), clinical (12.3 vs. 32.9%; odds ratio = 0.25; 95% confidence interval = 0.12-0.66; p < 0.05) and ongoing pregnancy (9.6 vs. 29.1%; odds ratio = 0.25; 95% confidence interval = 0.10-0.64; p < 0.05) rates were significantly lower in experimental group, compared with 79 controls. CONCLUSION: According to the results of this study, local injury to the endometrium on the day of oocyte retrieval disrupts the receptive endometrium and has a negative impact on implantation and IVF outcomes.

Comparing GnRH agonist long protocol and GnRH antagonist protocol in outcome the first cycle of ART.

PURPOSE: This prospective study evaluated the efficacy of gonadotropin-releasing hormone (GnRH) antagonist protocol in comparison with the GnRH agonist protocol in the first cycle of assisted reproductive technique (ART). METHODS: We randomized 235 patients undergoing ART for the first time. The first group was stimulated with a standard long protocol and the second group stimulated with GnRH antagonis. RESULTS: There was no statistically significant difference in the age, infertility cause, basal FSH, BMI, the number of oocytes retrieved, number of M2 oocytes, embryo obtained and endometrial thickness between the two groups. But Serum estradiol, consumption of gonadotropins and ovarian hyperstimulation syndrome were significantly lower in the antagonist protocol. Cancellation rate of embryo transfer due to poor-quality embryo in the antagonist protocol was higher, but it was not significant. There was no significant difference in the clinical pregnancy and ongoing pregnancy between the two groups. CONCLUSION: GnRH-antagonist is an effective, safe, and well-tolerated alternative to agonist in the first cycle of ART.

Prediction of high ovarian response to controlled ovarian hyperstimulation: anti-Müllerian hormone versus small antral follicle count (2-6 mm).

PURPOSE: To evaluate the predictive value of basal serum anti-müllerian hormone level and small antral follicle count for high ovarian response to controlled ovarian hyperstimulation. METHODS: A total of 159 patients were prospectively included. Basal serum anti-müllerian hormone and small antral follicle count (2-6 mm) were measured. RESULTS: Small antral follicle count and anti-müllerian hormone have similar predictive accuracy for high ovarian response with area under curve of 0.961 and 0.922, respectively. The sensitivity and specificity for prediction of high ovarian response were 89% and 92% for small antral follicle count and 93% and 78% for anti-müllerian hormone at the cutoff values of > or = 16 and > or = 34.5 pmol/l, respectively. CONCLUSIONS: Small antral follicle count and anti-müllerian hormone are equally accurate predictors of high ovarian response and facilitate determination of the optimal strategy for controlled ovarian hyperstimulation.