Is the Co-administration of Metformin and Clomiphene Superior to Induce Ovulation in Infertile Patients With Poly Cystic Ovary Syndrome and Confirmed Insulin-Resistance: A Double Blind Randomized Clinical Trial.

Objective: This study aimed to compare the effects of clomiphene citrate (CC) combined with metformin or placebo on infertile patients with poly cystic ovary syndrome (PCOS) and insulin resistance (IR). Materials and methods: We included 151 infertile women with PCOS and IR in a university hospital from November 2015 to April 2022 in this prospective, double-blind, randomized, placebo-controlled trial. Patients were randomized into two groups; group A: received CC plus metformin (n = 76) and group B: received CC plus placebo (n = 75). The ovulation rate was the main outcome measure. Clinical pregnancy, ongoing pregnancy, live birth and abortion rates were secondary outcome measures. Results: There was no remarkable difference in ovulation rate in two groups. Moreover, no significant changes were observed in clinical pregnancy, ongoing pregnancy, live birth and abortion rates between two groups. A larger proportion of women in group A suffered from side effects of metformin (9.3% versus 1.4%; p=0.064), although this was not significant. Conclusion: In IR infertile women with PCOS, metformin pre-treatment did not increase the ovulation, clinical pregnancy and live birth rates in patients on clomiphene citrate.

Marginal differences in preimplantation morphokinetics between conventional IVF and ICSI in patients with preimplantation genetic testing for aneuploidy (PGT-A): A sibling oocyte study.

OBJECTIVE: This study aimed to analyze the morphokinetic behaviour between conventional IVF and ICSI, in cycles with preimplantation genetic testing for aneuploidies (PGT-A). MATERIALS: A randomized controlled trial (NCT03708991) was conducted in a private fertility center. Thirty couples with non-male factor infertility were recruited between November 2018 and April 2019. A total of 568 sibling cumulus oocyte complexes were randomly inseminated with conventional IVF and ICSI and cultured in an Embryoscope time-lapse system. The morphokinetic behaviour of IVF/ICSI sibling oocytes was analysed as primary endpoint. As secondary endpoints, morphokinetic parameters that predict blastocysts that will be biopsied, the day of biopsy, gender and euploid outcome was assessed. RESULTS: When comparing IVF to ICSI, only the time to reach the 2-cell stage (t2) was significantly delayed for IVF embryos: OR: 1.282 [1.020-1.612], p = 0.033. After standardizing for tPNf (ct parameters), only Blast(tStartBlastulation-t2) remained significant: OR: 0.803 [0.648-0.994], p = 0.044. For the analysis of zygotes that will be biopsied on day 5/6 versus zygotes without biopsy, only early morphokinetic parameters were considered. All parameters were different in the multivariate model: ct2: OR: 0.840 [0.709-0.996], p = 0.045; ct6: OR: 0.943 [0.890-0.998], p = 0.043; cc2(t3-t2): OR: 1.148 [1.044-1.263], p = 0.004; cc3(t5-t3): OR: 1.177 [1.107-1.251], p<0.0001. When comparing the development between blastocysts biopsied on day 5 versus day 6, only three morphokinetic parameters were significant: cc2(t3-t2): OR: 1.394 [1.010-1.926], p = 0.044; ctBlastocyst: OR: 0.613 [0.489-0.768], p<0.0001 and ctExpandedBlastocyst: OR: 0.913 [0.868-0.960], p = 0.0004. Multivariate analysis of gender and ploidy did not reveal differences in morphokinetic behaviour. CONCLUSION: Minor morphokinetic differences are observed between IVF and ICSI. Early in the development, distinct cleavage patterns are observed between embryos that will be biopsied or not.

Anti-Müllerian hormone is an independent marker for oocyte survival after vitrification.

RESEARCH QUESTION: This study explored the relationship between anti-Müllerian hormone (AMH) and oocyte survival after vitrification. The association between AMH and blastocyst formation after oocyte vitrification was also assessed. DESIGN: A retrospective observational analysis was performed in a private IVF centre. A total of 4507 metaphase-II warmed oocytes were included from 450 couples, predominantly of Arab ethnicity. Between August 2015 and August 2018, couples underwent 484 intracytoplasmic sperm injection (ICSI) treatments using vitrified-warmed oocytes. RESULTS: Patients' median age ± SD was 36.2 ± 6.1 years, AMH concentration 2.6 ± 3.4 ng/ml and body mass index (BMI) 26.5 ± 4.6 kg/m2. The oocyte survival rate after vitrification was 87.37 ± 20.42%. AMH concentration showed a significant correlation (Kendall's tau 0.087, P = 0.0079) with oocyte survival rate independent of oocyte yield. Correlation was significant (odds ratio 1.041, 95% confidence interval 1.007-1.077, P = 0.018) when a multivariant model was applied that included AMH, age and BMI. The receiver operating characteristic curve showed an AMH cut-off value of 1.09 ng/ml that could obtain at least a 70% survival rate, with an area under the curve of 0.669. Regarding embryo development in ICSI cycles including fresh and warmed oocytes for the same patient, blastocyst formation rate was higher in fresh compared with warmed oocytes (P < 0.001). In this subgroup no significant correlation was seen between fertilization or blastocyst rate and AMH concentration. CONCLUSIONS: AMH concentration showed a significant correlation with oocyte survival. Blastocyst formation was significantly lower after oocyte vitrification, but no correlation was found with AMH. Clinicians should carefully evaluate oocyte vitrification for patients with AMH below 1.09 ng/ml and consider embryo accumulation for these patients in preference to oocyte accumulation.

Anti-müllerian Hormone During Natural Cycle Presents Significant Intra and Intercycle Variations When Measured With Fully Automated Assay.

Anti-Müllerian hormone (AMH) is an important ovarian reserve marker for baseline assessment and therapeutic strategy in fertility treatments, which is considered reliable when measured on any day of the cycle. Recent data have pointed toward significant fluctuations of AMH and questioned whether a single measurement is reliable for clinical decision-making. The aim of this study was to evaluate whether the AMH does have significant variations during a natural cycle when a fully automated assay is used for the sample analysis. We performed a prospective study including healthy volunteers with regular cycles, from April to December 2017. Blood samples for AMH, FSH, LH, estradiol, and progesterone were obtained on day 2/3, day 10, day of LH surge, luteal phase and day 2/3 of subsequent menses. AMH analysis was performed with Elecsys® AMH automated assay. Trial was registered with clinical.trials.gov: NCT03106272. One hundred samples from 22 women with a mean age of 30.74 ± 0.11 years and a BMI of 23.23 ± 0.63 kg/m2 were analyzed. There was a substantial longitudinal fluctuation in AMH levels, indicated by the coefficient of variation (CV) intra-cycle of 0.2070 ± 0.143. A positive correlation between LH and AMH concentrations was found at the moment of LH rise (p < 0.0001). Absolute intra-individual inter-cyclic variability was 0.75 ng/mL (range: 0.03-2.81 ng/mL) and inter-cycle CV was 0.28 (Confidence interval: 0.16-0.39; p < 0.0001). According to our results, with the use of a fully automated assay in natural cycle, AMH shows significant intra- and inter-cycle variations, which are not caused by analytical variability. Future investigations, evaluating AMH dynamics and the best time for AMH assessment should be conducted.

The effects of cancer therapy on women's fertility: what do we know now?

Due to the improvements of cancer treatment, the survival rate of cancer increased over the last decades. One of the detrimental side effects of cytotoxic treatment is the impairment or loss of fertility. Having a family is one of the important aspects for long-time survivors. The impact of gynecologic cancer on fertility depends on the site and kind of the cancer disease, the oncologic therapeutic regimen and additional the age of the patient. In cancer of the internal genital organs, fertility-preserving surgery techniques should be used, if possible. In case, that cytotoxic treatment has to be applied, fertility preservation techniques should be implemented into the oncologic treatment.

Absence of luteal phase defect and spontaneous pregnancy in IVF patients despite GnRH-agonist trigger and "freeze all policy" without luteal phase support: a report of four cases.

Human chorionic gonadotropin (hCG) is commonly used for final oocyte maturation in "in vitro fertilization" (IVF)-treatment cycles, however, the main important risk is development of severe ovarian hyperstimulation syndrome (OHSS). OHSS can almost be avoided by using gonadotrophin-releasing-hormone agonist for final oocyte maturation in an antagonist protocol. However, primarily this approach lead to a very poor reproductive outcome, despite the use of a standard luteal phase support. The reason seems to be severe luteolysis. Obviously, luteolysis post-gonadotropin-releasing-hormone-agonist (post-GnRH-a) trigger is individual specific, and not all patients will develop a complete luteolysis, as expected previously. Luteolysis can been reverted by the administration of hCG. Unprotected intercourse around the time of ovulation induction and oocyte retrieval can lead to a spontaneous conception in IVF treatment and, endogenous hCG, produced by the trophoblast, will rescue the corpora lutea. Therefore, one should not rely on complete luteolysis after GnRH-a triggering and, especially patients for egg donation and pre-implantation-genetic diagnosis for single gene disorder, have to be counselled to avoid unprotected intercourse.

Avoiding ovarian hyperstimulation syndrome with the use of gonadotropin-releasing hormone agonist trigger.

Ovarian hyperstimulation syndrome (OHSS) is one of the most serious, and potentially lethal, complications of controlled ovarian stimulation (COS). Induction of final oocyte maturation with a bolus of gonadotropin-releasing hormone (GnRH) agonist (GnRHa), instead of the criterion standard hCG, in patients undergoing ovarian stimulation significantly reduces the risk of OHSS and could be considered to be more physiologic. A bolus of GnRHa used in this context also acts as a luteolytic agent. From a clinical point of view, the most significant benefit of GnRHa trigger is its ability to induce quick and reversible luteolysis and thus reducing the risk of OHSS development. This paper describes the pathophysiology of OHSS, focusing specifically on the luteolytic benefits of using GnRHa to decrease OHSS and the possible corpus luteum rescue modalities available.

Severe ovarian hyperstimulation syndrome after gonadotropin-releasing hormone (GnRH) agonist trigger and "freeze-all" approach in GnRH antagonist protocol.

OBJECTIVE: To report two cases with GnRH agonist triggering and a freeze-all approach in a GnRH antagonist protocol resulting in the development of severe ovarian hyperstimulation syndrome (OHSS), requiring hospitalization and peritoneal drainage. DESIGN: Two case reports. SETTING: A tertiary referral center and an obstetrics and gynecology department of a hospital. PATIENT(S): Case 1 and case 2: severe OHSS with abdominal distension, ascites development, and hemoconcentration. INTERVENTION(S): Case 1 and case 2: diagnosed by clinical, hematologic, and ultrasound findings. Hospitalization, IV infusion, and peritoneal drainage. MAIN OUTCOME MEASURE(S): Symptomatic treatment and prevention of further complication. RESULT(S): Complete recovery. CONCLUSION(S): Two cases of severe OHSS after GnRH agonist trigger in a GnRH antagonist protocol without the administration of any hCG for luteal-phase support. Clinicians have to be aware that even the sequential approach to ovarian stimulation with a freeze-all attitude does not completely eliminate OHSS in all patients.

Gene expression profile in the endometrium on the day of oocyte retrieval after ovarian stimulation with low-dose hCG in the follicular phase.

The past decade has seen growing interest in ovarian stimulation protocols with GnRH antagonists in an effort to reduce the incidence of potential complications, such as cyst formation and ovarian hyperstimulation syndrome, and thus improve the clinical experience for patients. Current assisted reproductive technique programmes also increasingly utilize milder protocols for ovarian stimulation. In a recently published randomized controlled trial, we showed that low-dose hCG can be utilized clinically to replace recombinant FSH (rFSH) during the late follicular phase in a GnRH antagonist protocol. This regimen leads to a significant reduction in rFSH consumption, while the ICSI outcome, in terms of oocyte yield and ongoing pregnancy rate, remains comparable with the control regimen of rFSH plus a GnRH antagonist. In the present study, the influence of the administration of low-dose hCG on the endometrium was assessed. A comparison was made between two protocols for ovarian stimulation with GnRH antagonists, namely the classical protocol with rFSH and the protocol with low-dose hCG in the late follicular phase. We analysed the morphological pattern and gene expression profile of human endometrium on the day of oocyte retrieval. No morphological differences were observed and only a minimal set of 65 differentially expressed probe sets between the treatment groups were identified, enabling a similar efficacy to support implantation.

Cyclooxygenase-2 network as predictive molecular marker for clinical pregnancy in in vitro fertilization.

The gene expression of human endometrium on the day of oocyte retrieval of pregnant and nonpregnant patients in a stimulated IVF cycle was compared in two independent groups with different GnRH-antagonist ovarian stimulation protocols. The present data suggest that increased gene expression of cyclooxygenase-2, together with the expression of other molecules in the cyclooxygenase-2 network, on the day of oocyte retrieval in GnRH-antagonist cycles coincides with a lower probability of achieving a clinical pregnancy in this cycle.

Cryopreserved-thawed human embryo transfer: spontaneous natural cycle is superior to human chorionic gonadotropin-induced natural cycle.

OBJECTIVE: To assess whether there is a difference in the ongoing pregnancy rate after transferring frozen-thawed embryos in natural cycles with spontaneous LH-P rise compared with natural cycles controlled by hCG for final oocyte maturation and ovulation. DESIGN: Randomized controlled trial. SETTING: Tertiary referral center. PATIENT(S): A total of 168 patients were assigned randomly to undergo frozen ET on day 3 from October 2007 until November 2008. Finally, analysis was performed in 124 patients; 61 belonged to the spontaneous LH group and 63 to the hCG group. INTERVENTION(S): In the spontaneous LH group the transfer was planned 5 days after the LH surge. In the hCG group, the cryopreserve ET was planned 5 days after the administration of 5000 IU of hCG, when an endometrial thickness of ≥7 mm and a follicle of ≥17 mm were present on ultrasound examination. MAIN OUTCOME MEASURE(S): Ongoing pregnancy rate. RESULT(S): The study was terminated early, when a prespecified interim analysis found a significantly higher ongoing pregnancy rate in the spontaneous LH group as compared with the hCG group (31.1% vs. 14.3%; difference 16.9%, 95% confidence interval 4.4%-28.8%). CONCLUSION(S): The results suggest the superiority of the natural cycle as compared with the natural cycle controlled by hCG administration in cryothawed ET cycles.

In vitro fertilization pregnancy in a patient with proven chronic endometritis.

OBJECTIVE: To report an in vitro fertilization (IVF) pregnancy in a patient with histologically confirmed chronic endometritis before the IVF treatment without prior antibiotherapy. DESIGN: Case report. SETTING: Academic reproductive medicine unit. PATIENT(S): A 30-year-old woman with primary infertility due to mild oligoasthenoteratospermia of the male partner. INTERVENTION(S): Diagnostic hysteroscopy and endometrial biopsy. MAIN OUTCOME MEASURE(S): Delivery after the first IVF. RESULT(S): Histologic examination of the endometrium revealed chronic endometritis. The patient delivered a healthy boy at 40 weeks' gestation after the first IVF treatment. CONCLUSION(S): Our findings suggest that the impact of chronic endometritis on infertility and IVF outcome should be further investigated in prospective randomized studies.

In GnRH antagonist/rec-FSH stimulated cycles, advanced endometrial maturation on the day of oocyte retrieval correlates with altered gene expression.

BACKGROUND: Previously, advanced endometrial maturation on the day of oocyte retrieval in GnRH antagonist and -agonist IVF cycles was observed. In these cycles, endometrial advancement exceeding 3 days between the histological dating and the cycle day never resulted in an ongoing clinical pregnancy. In this study, the gene expression of human endometrium on the day of oocyte retrieval in GnRH antagonist/rec-FSH cycles was analyzed, in correlation with the morphological dating. METHODS: Biopsies were taken on the day of oocyte retrieval in 47 patients with 1 or 2 embryos replaced on Day 3 in the same cycle. Endometrial dating was performed according to Noyes' criteria. Biopsies from 11 patients were analyzed for gene expression with the Affymetrix HG U133 Plus 2 microarray. Data analysis, clustering and pathway analysis were performed with GCOS, GeneSpring 7.3 and Ingenuity, respectively. RESULTS: According to Noyes' criteria, all endometria taken on the day of oocyte retrieval showed an advanced maturation, ranging from +d2 to +d4. The patients with a subsequent clinical pregnancy all showed a histological dating corresponding to +d2 or +d3. When comparing endometria +d2-3 to +d4, the microarray results showed a differential expression of 2550 probe sets. Significantly up-regulated genes were SERPINB6, FOXO3A, SOX17 and CDC42. Down-regulated genes of interest were NRP1, HOXA10 and OSF2. Principal component analysis and hierarchical clustering demonstrated two distinct clusters. CONCLUSIONS: In stimulated cycles, endometrial gene expression on the day of oocyte retrieval discriminates between women with and without histologically advanced endometrial maturation exceeding 3 days and supports histological dating results by Noyes' criteria.

Rescue IVF and coasting with the use of a GnRH antagonist after ovulation induction.

The major risks of exogenous gonadotrophin therapy for ovulation induction in a patient with polycystic ovaries (PCO) are multiple pregnancies and ovarian hyperstimulation syndrome (OHSS). This case report describes a 23-year-old patient, who was referred to the Centre for Reproductive Medicine in Brussels because of a high risk of developing OHSS and rising LH following ovulation induction with a low-dose step-up protocol using gonadotrophins. After counselling the patient, the decision was made to perform a rescue IVF cycle. The patient was first coasted with 0.25 mg ganirelix; the serum oestradiol concentrations decreased and the LH peak was successfully suppressed. No OHSS occurred. An ongoing twin pregnancy was achieved after the transfer of two embryos. This case report demonstrates the feasibility of coasting with LH-releasing hormone (LHRH) antagonists (0.25 mg ganirelix) and the usefulness of the antagonists for ovulation induction cycles in patients who need rescue IVF.