Clomiphene citrate versus high doses of gonadotropins for in vitro fertilisation in women with compromised ovarian reserve: a randomised controlled non-inferiority trial.

BACKGROUND: The aim of the present randomised controlled non-inferiority trial is to test whether in women with compromised ovarian reserve requiring in vitro fertilisation, a protocol of ovarian stimulation using exclusively clomiphene citrate performs similarly to a regimen with high doses of gonadotropins. METHODS: Women with day 3 serum FSH > 12 IU/ml on at least two occasions or previous poor response to hyper-stimulation were recruited at four Italian infertility units. Selected women were allocated to clomiphene citrate 150 mg/day from day 3 to day 7 of the cycle (n=145) or to a short protocol with GnRH agonist 0.1 mg and recombinant FSH 450 IU daily (n=146). They were randomised by means of a computer-generated list into two groups. The study was not blinded. The main outcome of the study was the delivery rate per started cycle. RESULTS: The study was interrupted after the scheduled two years of recruitment before reaching the sample size. 148 women were allocated to clomiphene citrate and 156 to the short protocol with high doses of gonadotropins; 124 and 125 participants were analysed in the groups, respectively. Women allocated to high doses of gonadotropins retrieved more oocytes and had a higher probability to perform embryo-transfer. However, the chances of success were similar. The delivery rate per started cycle in women receiving clomiphene citrate and high-dose gonadotropins was 3% (n=5) and 5% (n=7), respectively (p=0.77). The mean estimated cost per delivery in the two groups was 81,294 and 113,107 Euros, respectively. No side-effects or adverse events were observed. CONCLUSIONS: In women with compromised ovarian reserve selected for in vitro fertilisation, ovarian stimulation with clomiphene citrate or high-dose gonadotropins led to similar chances of pregnancy but the former is less expensive. TRIAL REGISTRATION: Trial registered on http://www.clinicaltrials.gov (NCT01389713).

Pregnancy outcome in women with endometriomas achieving pregnancy through IVF.

BACKGROUND: There is a growing consensus that ovarian endometriomas should not be systematically removed in women selected for IVF. However, some recent evidence suggested that the presence of these cysts may negatively affect the course of pregnancy. METHODS: We set up a multicenter retrospective cohort study, including two infertility units. We analyzed data from patients achieving singleton clinical pregnancies through IVF comparing the pregnancy outcome between 78 pregnant women with endometriomas at the time of IVF and 156 patients who achieved pregnancy through IVF without endometriomas. RESULTS: The number of live births in women with and without endometriomas were 61 (78%) and 130 (83%), respectively (P = 0.39). The adjusted odds ratio (OR) of live birth in affected cases was 0.79 [95% confidence interval (CI): 0.38-1.68]. No differences were observed in late pregnancy and neonatal outcomes between the two groups. In particular, the rate of preterm birth and small-for-gestational age (SGA) was similar. The adjusted ORs were 0.47 (95% CI: 0.14-1.54) and 0.56 (95% CI: 0.12-2.56), respectively. CONCLUSIONS: Women with endometriomas achieving pregnancy through IVF do not seem to be exposed to a significant increased risk of obstetrical complications.

Consistent and predictable delivery rates after oocyte vitrification: an observational longitudinal cohort multicentric study.

BACKGROUND: An efficient method for cryopreservation of human oocytes may offer solutions to legal and ethical problems in routine infertility programs and may also be used for fertility preservation for medical and social reasons. METHODS: We conducted an observational longitudinal cohort multicentric study to investigate the efficacy and reproducibility of oocyte cryopreservation outcomes in IVF/ICSI cycles. Moreover, the effects of patient and cycle characteristics on the delivery rate (DR) were analyzed. RESULTS: In 486 cycles performed in 450 couples, 2721 oocytes were warmed and 2304 of them survived cryopreservation (84.7%). Of the 2182 oocytes subjected to ICSI, the rates of fertilization and development to top-quality embryos were 75.2 and 48.1%, respectively. A total of 128 deliveries were obtained (26.3% per cycle and 29.4% per transfer) for 450 patients (28.4%) and 147 babies were live born from 929 embryos transferred (15.8%). The forward logistic regression analysis on a per patient basis showed that female age [odds ratio (OR): 0.93, 95% confidence interval (CI): 0.88-0.98], number of vitrified oocytes (OR: 1.08, 95% CI: 1.01-1.17) and the day of transfer (OR: 1.97, 95% CI: 1.14-3.42) influenced DR. By recursive partitioning analysis, it can be estimated that more than eight oocytes vitrified are required to improve the outcome (22.6 versus 46.4% DR, respectively). When fewer oocytes are available in women aged >38 years, results are dramatically reduced (12.6 versus 27.5% DR, respectively). Conversely, when >8 oocytes are available, blastocyst culture represents the most efficient policy (62.1% DR; data from one center only). CONCLUSIONS: Oocyte vitrification is an efficient and reliable approach, with consistent results between centers and predictable DRs. It should be applied routinely for various indications. A predictive model is proposed to help patient counselling and selection.

IVF and endometriosis-related symptom progression: insights from a prospective study.

BACKGROUND: A possible and neglected concern in women with endometriosis undergoing IVF is the potential risk of progression of the disease. We set up a prospective study mainly aimed at evaluating the impact of IVF on endometriosis-related symptoms. MATERIALS AND METHODS: Women with surgical or echographic diagnosis of endometriosis and selected for IVF were included. In the month preceding the IVF attempt and at a second evaluation 3-6 months after the cycle, women who did not get pregnant underwent clinical assessment and transvaginal ultrasonography. Each patient was requested to complete a questionnaire on the presence, severity and modifications of endometriosis-related symptoms before and after the IVF cycle. RESULTS: Overall, 64 patients completed the study protocol. The Biberoglu-Behrman Scores and the Verbal Rate Scales for dysmenorrhea, dispareunia and chronic pelvic pain did not worsen after the procedure. Other endometriosis-related symptoms also did not change. There was no modification in size and number of endometriomas and deep peritoneal nodules. The number (%) of women reporting general improvement and worsening were 14 (22%) and 7 (11%), respectively. CONCLUSIONS: IVF does not expose women to a consistent risk of endometriosis-related symptoms progression.

Prevalence and incidence of depressive and anxious symptoms in couples undergoing assisted reproductive treatment in an Italian infertility department.

OBJECTIVE: We have conducted a longitudinal observational study in order to evaluate the prevalence and the incidence of depressive and anxious symptoms in women and men seeking infertility treatment and to analyze associated factors or risk factors for these kinds of disorders. STUDY DESIGN: A total of 1000 consecutive couples that visited our center for the first time were asked to join this study. Depressive and anxious symptoms were assessed with self-rating Zung Depression Scale (ZDS) and Zung Anxiety Scale (ZAS) questionnaires. A second assessment was planned at the time of ß HCG dosage (or at the moment of cycle suspension). A standard questionnaire was used to investigate socio-demographic information and the psychological aspects of couples undergoing in vitro fertilization (IVF) treatment. The fertility history and outcome of IVF treatment were collected from patients' medical records. RESULTS: 14.7% of women had anxious symptoms and 17.9% depressive symptoms, whereas 4.5% of men had anxious symptoms and 6.9% depressive symptoms. Women with depressive and anxious symptoms were younger, more often had an anxious partner and had a longer history of infertility. Men with depressive and anxious symptoms more frequently had a temporary job, they had an anxious partner and they were more frequently at the first in vitro fertilization (IVF) cycle. The incidence of depressive and/or anxious symptoms was 18.5% in women and 7.4% in men. Age and previous IVF treatments seem not to be associated with incidence of depressive or anxious symptoms. CONCLUSION: Both the prevalence and incidence of depressive and/or anxious symptoms in couples undergoing IVF treatment were worthy of note and should not be underestimated. More attention must be paid to psychological aspects in young women and in couples with a long history of infertility or previous failure treatments. Having an anxious partner was associated with anxious and depressive symptoms. For this reason, both males and females might benefit from psychological intervention, which could also help them to be supportive to each other.

Use of parthenogenetic activation of human oocytes as an experimental model for evaluation of polar body based PGD assay performance.

PURPOSE: To develop an experimental model to assess the feasibility of polar body preimplantation genetic diagnosis without requiring oocyte fertilization. METHODS: First polar body was removed from donated oocytes and second polar body was biopsied after parthenogenetic activation. Molecular analysis on both polar bodies involved a fluorescent multiplex polymerase chain reaction of short-tandem repeat markers, closely linked to genes of interest. Main outcome measures were: allele segregation through polar bodies and haploid nucleus, recombination rates between alleles and frequency of Allele Drop Out. RESULTS: Twenty-six out of 39 oocytes extruded a second polar body after activation. Ninety-two percent of the first polar bodies and 20 out of 26 (77%) second polar bodies were successfully amplified. Eighty percent of first polar bodies were heterozygous for CFTR and 55% for HBB. Analysis of second polar bodies predicted the genotype of the oocytes in case of heterozygous first polar body, and validated results in homozygous cases. Frequency of allele drop out was 4%. CONCLUSIONS: Our model confirms that polar body preimplantation genetic diagnosis for single gene disorders can be evaluated using parthenogenetic oocytes and offers an option to set up procedures without requiring oocyte fertilization.

Fibroids not encroaching the endometrial cavity and IVF success rate: a prospective study.

BACKGROUND The impact of fibroids, not encroaching the endometrial cavity, have on the rate of success of IVF is still controversial. Recent meta-analyses suggest a detrimental effect of intramural lesions but not subserosal lesions. However, they also emphasize the need for further evidence. In order to elucidate this, we designed a prospective cohort study to compare the rate of success of IVF in women with and without fibroids. METHODS Exposed women were those with asymptomatic intramural or subserosal fibroids with a diameter below 50 mm and who were selected for IVF. Unexposed women were those free of fibroids, who were matched to cases by age and number of previous IVF cycles. All recruited patients underwent hystero-sonography to rule out intra-cavitary lesions. RESULTS There were 119 cases and 119 controls recruited. The number of clinical pregnancies in women with and without fibroids was 28 (24%) and 22 (19%), respectively (P= 0.43). The adjusted odds ratio (OR) for pregnancy in affected women was 1.38 [95% confidence interval (CI): 0.73-2.60]. The number of deliveries was 22 (18%) and 16 (13%), respectively (P= 0.38). The adjusted OR was 1.45 (95% CI: 0.71-2.94). Similar results emerged when focusing exclusively on women carrying intramural lesions (n= 80 couples). There was no significant relationship between clinical outcome and either the number or size of the fibroids. CONCLUSIONS In asymptomatic patients selected for IVF, small fibroids not encroaching the endometrial cavity did not impact on the rate of success of the procedure.

Hyperstimulation during IVF cycles does not modify dimensions of small subserosal and intramural leiomyomas.

To evaluate the influence of IVF on the dimension of leiomyomas, we selected 72 women with small intramural or subserosal leiomyomas and assessed the size of these lesions before and after the treatment cycle. The mean ± SD diameters of the tumors at these two time points were 20.5 ± 9.5 and 20.6 ± 10.2 mm, respectively, thus supporting the conclusion that IVF does not influence the growth of these lesions.

Effects of two vitrification protocols on the developmental potential of human mature oocytes.

The aim of the present study was to compare an 'open' vitrification protocol to a 'closed' vitrification protocol for mature human oocytes. A prospective comparison between fresh and sibling vitrified oocytes and a retrospective comparison between the two vitrification protocols were performed. For recruited patients undergoing an IVF cycle, two or three fresh oocytes were inseminated with intracytoplasmic sperm injection (ICSI) and the remaining three or more oocytes were vitrified according to manufacturer's instructions with a 'closed' or an 'open' vitrification system. After an unsuccessful fresh cycle, oocytes were warmed and inseminated with ICSI. Embryological parameters were recorded and compared between fresh and sibling vitrified oocytes (intrapatient) as well as between the two vitrification techniques (interpatient). Oocytes vitrified with the 'closed' system showed significantly lower fertilization and cleavage rates and a reduction in the quantity and quality of obtained embryos compared with fresh sibling oocytes (P<0.001). On the contrary, the same parameters were similar between fresh and sibling oocytes vitrified using the 'open' system. The retrospective comparison between the two vitrification protocols also showed a significant increase in clinical pregnancy rate and a reduced proportion of cancelled cycles using the 'open' system (P<0.01).

Procedure for rapid oocyte selection based on quantitative analysis of cumulus cell gene expression.

PURPOSE: To develop a procedure for the analysis of gene expression in cumulus cells during the interval between ovum pick up and insemination to select the best oocytes for fertilization. METHODS: Five RNA extraction methods, three reverse transcription procedures followed by Real-time quantitative PCR and one single-step mRNA quantification kit were tested to measure the expression of five genes in cumulus cells. RESULTS: Two RNA extraction kits gave the best combination of efficiency and purity. One reverse transcription procedure gave the best speed and efficiency. The single-step kit required more biological material than would be available from single cumulus oocyte complexes (COCs). CONCLUSIONS: Our test identified a combination of RNA extraction and reverse transcription procedures that enables the level measurement of 5 selected cumulus cell transcripts within 4 h. Using this combination it was possible to obtain a reliable quantification of gene expression in 44 out of 46 individual COCs collected from seven patients.

Blood loss during transvaginal oocyte retrieval.

BACKGROUND/AIMS: Limited information is available regarding the quantity of blood loss associated with uncomplicated transvaginal oocyte retrieval. The aim of the present study was evaluating the quantity of such a loss. METHODS: One hundred and fifty consecutive women undergoing oocyte retrieval were recruited. They underwent blood test assessment and ultrasonographic transvaginal evaluation at three different times: (1) immediately before initiating oocyte retrieval, (2) 4-6 h later, and (3) 72 h later. RESULTS: At 4-6 h after oocyte retrieval, the red blood cell count and the hemoglobin concentration were significantly reduced, whereas pelvic free fluid had significantly increased. The estimated median (Interquartile range) blood loss was 72 (-8/162) ml. None of the recruited women was found to have a hemoglobin reduction >2 g/day or an increase in the pelvic free fluid >200 ml or a calculated blood loss >500 ml (0.0%, 95% CI: 0.0-2.4%). No significant worsening from baseline was observed at the 72 h evaluation. CONCLUSIONS: The quantity of blood loss following oocyte retrieval is clinically unremarkable in the vast majority of women.

The clomiphene citrate challenge test (CCCT) in women with elevated basal FSH: biological significance and predictive value.

OBJECTIVE: The rationale of the clomiphene citrate challenge test (CCCT) is that day 10 serum FSH is influenced by the quality of the recruited oocytes. Biological evidence supporting this assumption is, however, lacking. The aim of this study is to investigate the relationship between results from the CCCT and the quantity and the quality of the recruited oocytes. STUDY DESIGN: Patients selected for in vitro fertilization (IVF) and who were found to have elevated basal FSH (n=114) underwent an IVF cycle using follicles developing during CCCT. Subsequently, a subgroup of patients (n=89) underwent a second cycle receiving high doses of gonadotropins. The main outcome considered was the transfer of viable embryos. RESULTS: During the CCCT cycle, the area under the receiver operating characteristics (ROC) curves for day 3 and day 10 serum FSH to predict embryo-transfer was 0.48 (95% CI, 0.37-0.60) and 0.74 (95% CI, 0.63-0.82), respectively. In the subsequent cycle, the area under the ROC curves for the two variables was 0.58 (0.43-0.72) and 0.58 (0.43-0.72), respectively. CONCLUSIONS: CCCT effectively mirrors the quantity and the quality of the recruited oocytes but its predictive value is low.