Comparison of the effects of two different trigger strategies - dual (hCG + Leuprolide) versus hCG trigger - in antagonist non-donor IVF: a randomized controlled trial.

OBJECTIVE: Conventionally, hCG is used as a 'faux' LH surge to bring final oocyte maturation due to structural similarity with LH. Although GnRH agonists induce a more physiological gonadotropin surge for follicular maturation, they have been associated with luteal phase deficiency. Our aim was to assess whether adding a gonadotropin-releasing hormone agonist (GnRHa) to hCG trigger improves oocyte maturation and the number of high-grade embryos in GnRH antagonist IVF cycles. METHODS: This was a single center, open-labelled, randomized controlled trial including 100 patients between 21-38 years (tubal factor, male factor, unexplained infertility, with normal ovarian reserve) undergoing IVF using the GnRH antagonist protocol. Patients were randomized to receive either the dual trigger (Leuprolide acetate 1mg + rhCG 250µg, n=50) or a single hCG trigger (rhCG 250µg, n=50). Analysis was done by ITT. Independent-t and chi-square tests were used in the comparisons of normally distributed quantitative variables and qualitative variables. RESULTS: With similar baseline characteristics, the number of MII oocytes (7.82 vs. 5.92, p=0.003) and day-3 grade-1 embryos (4.24 vs. 1.8, p<0.001) and consequently, number of embryos cryopreserved (2.68 vs. 0.94, p<0.001) were significantly higher in the dual trigger group. However, the fertilization (91.82% vs. 88.51%, p=0.184) and clinical pregnancy rates between the two groups (21% vs. 19.6%, p=0.770) were comparable. Serum LH levels 12 hours post trigger were high in the dual trigger group (46.23mIU/ml vs. 0.93mIU/ml, p<0.0001). CONCLUSIONS: This study found that the addition of GnRHa to hCG trigger leads to improved embryological outcomes and the possibility of cryopreserving surplus embryos, thereby increasing cumulative live births.

Using GnRH agonists in combination with hCG in antagonist ART cycles: A SCOPING Review of recent evidences.

Assisted Reproductive technology encompasses all techniques involving ovarian stimulation to produce high-quality oocytes and manipulation of both oocytes and sperm in vitro to produce embryos for the purpose of reproduction. The final maturation of oocytes induced by a "trigger" is a crucial step with the potential to affect in vitro fertilization outcomes. Human chorionic gonadotropin has traditionally been used as a substitute for luteinizing hormone to induce final oocyte maturation and meiosis. However, this practice may cause a potentially fatal iatrogenic complication known as ovarian hyperstimulation syndrome, which can cause significant morbidity and, in rare cases, death in otherwise healthy women. Thus, gonadotropin releasing hormone agonists have been promoted as a safer alternative for inducing oocyte maturation, albeit at the expense of luteal phase defect. Since then, various combinations of gonadotropin releasing hormone agonists and human chorionic gonadotropin have been tried. This scoping review evaluates these trigger combinations in various types of responders.

In vitro fertilization as an independent risk factor for perinatal complications: Single-center 10 years cohort study.

OBJECTIVES: Assisted Reproductive Technology (ART) has made great strides in the past forty-years, but no medical treatment comes without side effects. Despite several studies reporting high incidences of perinatal complications, the association is inconclusive. Also, the effect of racially and ethnically distinguished Asian population undergoing ART on perinatal outcomes is not well studied. Therefore, this study attempts to compare various perinatal outcome parameters in ART, and spontaneously conceived singleton pregnancies from a single high-volume tertiary care center. METHODS: This is a retrospective cohort study from a single tertiary infertility center, carried out from January 2011 to September 2020. The study included 1,125 IVF conceived babies (AB group) and 7,193 spontaneous conceived babies (SB group). The groups were compared using the Pearson Chi-square test and adjusted odds ratio, calculated using the multivariate analysis. RESULTS: Most of the perinatal complications, such as preterm birth (PTB), early preterm birth, low birth weight (LBW), extremely low birth weight, small for gestational age, large for gestational age babies, neonatal intensive care unit (NICU) admission, need for surfactant, meconium aspiration syndrome, neonatal seizures, intraventricular hemorrhage, hypoxic-ischemic encephalopathy, and patent ductus arteriosus was significantly increased in the AB group when compared to the SB group (p<0.05). In-vitro fertilization (IVF) independently increases the risk of LBW (aOR 2.530; 95% CI 2.194-2.917), PTB (aOR 4.004; 95% CI 3.496-4.587), NICU admission (aOR 2.003; 95% CI 1.610-2.492) and neonatal seizures (aOR 9.805; 95% CI 5.755-16.706).Conclusions: All ART-conceived pregnant patients should receive antenatal counselling regarding perinatal complications and should deliver at a tertiary care center with appropriate NICU support.

Establishment of Cut-off Values for Uterine and Peripheral Blood Natural Killer Cells During the Peri-implantation Period in Fertile Controls and Women with Unexplained Recurrent Implantation Failure.

Background: The purpose of the study was to determine the cut-off values for peripheral and uterine natural killer (pNK, uNK) cells in fertile controls and in women with recurrent implantation failure (RIF). Methods: In this study, 50 women with RIF and 50 fertile controls were enrolled. Midluteal endometrial biopsy samples from both cases and controls were obtained for CD 56+ cell immunohistochemistry labeling to identify uNK cells. Peripheral venous blood was also taken during the biopsy to detect pNK cells in peripheral blood mononuclear cells using flow cytometry. Cut-off values were obtained from fertile controls. Using a non-parametric Mann-Whitney U-test, the medians of the data sets were compared. Results: The median values for uNK and pNK cell levels in the control group were 7% and 11.6%, respectively. The median value for uNK cells in RIF patients was 9%, which was higher than the one in controls but not statistically significant (p-value of 0.689). The median pNK levels (11.6% vs. 12.4%) were comparable between the RIF group and the controls. Moreover, it was found that 68% of individuals had uNK cell counts below the reference value, while 32% had excessive levels exceeding 7%. Additionally, only 51.4% of the RIF group had increased pNK cells. Conclusion: The pNK cell cut-off values need to be used with caution because there was no difference between fertile controls and RIF women. If immunotherapy is recommended for RIF women, uNK cell testing should be used as the preferred approach.

Comparing maternal outcomes in spontaneous singleton pregnancies versus in vitro fertilization conception: Single-center 10-year cohort study.

OBJECTIVE: A successful assisted reproductive technique (ART) cycle is not flawless, and several studies have reported high incidences of maternal complications, but the association is inconclusive. In addition, the racial and ethnic effects of the Asian population undergoing ART on maternal outcomes is not well studied. This study attempts to compare various maternal outcome parameters ART and spontaneously conceived singleton pregnancies from a single high volume tertiary care centre. METHODS: A retrospective cohort study from a single tertiary infertility center was conducted from January 2011 to September 2020. The study included 1125 IVF conceived singletons (AP group) and 7193 spontaneous conceived singletons (SP group). The groups were compared using the Pearson Chi-square test and the adjusted odds ratio calculated using multivariate analysis. RESULTS: Maternal outcomes like gestational hypertension, pre-eclampsia, gestational diabetes (GDM), oligohydramnios, chorioamnionitis, operative, and instrumental delivery were significantly different in the two groups (p<0.05). The AP group had a significantly increased risk of GDM (aOR 1.093; 95% CI 1.076-1.110) and pregnancy-induced hypertension (PIH) (aOR 1.577; 95% CI 1.288-1.930) as compared to the SP group. IVF significantly increases the risk of abruption by 2 times (p=0.028), and independently increases the risk of caesarean section by 3.1-fold (p<0.001). But overall the IVF is the protective factor for oligohydramnios (p=0.024). CONCLUSIONS: ART increases the likelihood of pregnancy-related maternal complications, such as PIH, GDM, abruption, chorioamnionitis, and an increased rate of caesarean delivery. Thus, all patients undergoing ART procedures should receive pre-conceptional counselling regarding the associated obstetric risks and consider ART pregnancy as a high-risk pregnancy.

Two-six Hours is the Optimal Timing of Intracytoplasmic Sperm Injection After Oocyte Pickup: Single-centre 10 Years Cohort Study.

Background: Optimal incubation period for oocyte competence remains contentious despite intracytoplasmic sperm injection(ICSI) being in practice for 34 years. Dilemma exists as the current literature favors both early and delayed denudation with equivocal results. With ever-rising demand for the procedure this conundrum continues to plague the clinical outcomes. Aims: This study attempts to provide a consensus regarding optimal time duration required for incubating the oocytes after oocyte pickup(OPU) and time to perform ICSI. Settings and Design: A retrospective study in a tertiary centre. Materials and Methods: A retrospective 10-year cohort study including 726 ICSI cycles was conducted in a single tertiary care infertility centre. All cycles comprised at least one metaphase-II oocyte injected with one good quality sperm followed by fresh embryo transfer. The cohort was broadly divided into two groups: (a) Group 1: OPU-ICSI <4 hours(n=466) and (b) Group 2: OPU-ICSI>4 hours(n=260). Statistical Analysis Used: The fertilization(FR) and clinical pregnancy rates(CPR) were compared using the Pearson Chi-square test. The OPU-ICSI interval were subdivided into one-hourly intervals and CPR was compared after adjustment for multiple comparisons by holm method. Results: The FR and CPR were similar between Group 1 and Group 2(p>0.05). Comparing CPR for each one-hourly OPU-ICSI interval revealed no significant clinical difference (p>0.05) amongst one another, however, the CPR was maximum for 2-3 hours as the OPU-ICSI interval. Conclusion: With no significant clinical difference amongst various temporal groups, this study advocates and reinstates 2-6 hours as the optimal timing for ICSI after the OPU. This will also translate into better time management for both embryologists and clinicians and help them prioritise the laboratory workflow.

Designing adolescent sleep interventions with stakeholder input.

OBJECTIVE: Few sleep promotion programs for adolescents have involved stakeholders as part of the intervention development, which may contribute to their limited accessibility, scalability, acceptability, and feasibility. Specifically asking stakeholders for their input on how to modify factors impacting sleep is critical, as is identifying strategies for motivating sleep behavior change. We report qualitative feedback from stakeholders interested in improving adolescent sleep, data collected specifically to inform the development of an adolescent sleep promotion program. PARTICIPANTS: We conducted 9 focus groups (3 each for young adults (n = 8, ages 21-25), parents of adolescents (n = 12), and healthcare providers working with adolescents (n = 29) following a semistructured approach. DESIGN: Participants reported on contributors to good and poor sleep; motivators for improving sleep; strategies for promoting and sustaining behavior change; and feasibility of a proposed sleep promotion program. We coded and thematically analyzed focus group transcripts using inductive and deductive approaches. RESULTS: Moderate engagement in activities (eg, a job, sports) was seen as a contributor to good sleep, while having too many or too few activities was thought to contribute to poor sleep. Linking improved sleep with personalized outcomes of interest can enhance motivation for changing sleep. Strategies for behavior change should rely on increasing internal motivation, personalizing intervention content, and having parents model desired behaviors. CONCLUSIONS: Key stakeholders are critical to the development of acceptable interventions that can be implemented effectively in real-world settings. Future work should test whether the identified themes contribute to increased feasibility, scalability, and effectiveness of sleep programs.