The effect of gonadotrophin-releasing hormone agonist versus human chorionic gonadotrophin trigger on pregnancy and neonatal outcomes in Letrozole-HMG IUI cycles.

BACKGROUND: GnRHa and hCG are both used for oocyte maturation and ovulation triggering. However, GnRHa have a shorter half-life than hCG, which leads to luteal phase deficiency. Letrozole (LE) has been found to improve the luteal function. Thus, the choice of triggering strategy can be different in intrauterine insemination (IUI) cycles using LE and human menopausal gonadotropin (HMG). The aim of this study was to compare the pregnancy and neonatal outcomes of patients triggered with GnRHa versus hCG versus dual trigger in LE-IUI cycles. METHODS: This retrospective cohort study included 6,075 LE-HMG IUI cycles between January 2010 and May 2021 at a tertiary-care academic medical center in China. All cycles were divided into three groups according to different trigger strategies as hCG trigger group, GnRHa trigger group and dual trigger group. The primary outcome was clinical pregnancy rate. Logistic regression analysis was performed to explore other risk factors for clinical pregnancy rate. RESULTS: No significant difference was observed in clinical pregnancy rate between hCG, GnRHa and dual trigger cycles in LE-HMG IUI cycles (P = 0.964). The miscarriage rate was significantly lower in the GnRHa trigger group, and higher in the dual trigger group, compared with the hCG group (P = 0.045). Logistic analysis confirmed that triggering strategy was associated with miscarriage (aOR:0.427, 95%CI: 0.183-0.996, P = 0.049; aOR:0.298, 95%CI: 0.128-0.693, P = 0.005). No significant differences were observed regarding neonatal outcomes between the three groups. CONCLUSIONS: Our findings suggested that both GnRHa and dual trigger can be used to trigger ovulation in LE-HMG IUI cycles, but dual trigger must be used with caution.

Optimal lead follicle size in letrozole human menopausal gonadotrophin intrauterine insemination cycles with and without spontaneous LH surge.

RESEARCH QUESTION: What is the optimal lead follicle size in letrozole, human menopausal gonadotrophin and intrauterine insemination (IUI) cycles with and without spontaneous LH surges? DESIGN: This retrospective cohort study included 3797 letrozole HMG IUI cycles between January 2010 and May 2021. All cycles were divided into two groups: the HCG trigger group (trigger day LH ≤15 mIU/ml) and the spontaneous LH surge group (trigger day LH >15 mIU/ml). These two groups were subdivided into smaller groups based on the diameter of the follicles. The primary outcome measure was clinical pregnancy rate. Logistic regression analysis was conducted to explore other risk factors. RESULTS: In the HCG trigger group, the clinical pregnancy rate varied significantly, with rates of 20.8%, 14.9% and 11.8% for the 16.1-18.0, 18.1-20.0 and 20.1-22.0 mm groups, respectively (P = 0.005). In the spontaneous LH surge group, the pregnancy rate of follicles within 14.1-16.0 mm was significantly higher than that of follicles within 20.1-22.0 mm (adjusted OR 0.533, 95% CI 0.308 to 0.923, P = 0.025). Also, patients with two lead follicles were 2.569 times more likely to achieve a clinical pregnancy than those with only one lead follicle (adjusted OR 2.569, 95% CI 1.258 to 5.246, P = 0.010). The duration of infertility was also found to be a common influencing factor in both groups. CONCLUSIONS: The optimal lead follicle size was between 16.1 and 18.0 mm in HCG-triggered letrozole HMG IUI cycles. If the lead follicle size is relatively small (14.1-18.0 mm) when a spontaneous LH surge occurs, there is no need to cancel the IUI cycle.

The comparison of two different protocols ultra-long versus medroxyprogesterone acetate in women with ovarian endometriosis: a prospective randomized controlled trial.

BACKGROUND: This study aimed to investigate the medroxyprogesterone acetate (MPA) + HMG protocol vs ultra-long gonadotrophin releasing hormone (GnRH) agonist protocol in patients with advanced ovarian endometriosis who received in vitro fertilization (IVF). METHODS: Three hundred patients with advanced ovary endometriosis who underwent IVF were included, and embryological and clinical outcomes were assessed between March 2017 and September 2017. Patients were divided into MPA + HMG group and 1-month ultra-long GnRHa protocol group. RESULTS: Lower hMG dose and shorter medication time were found in the MPA + HMG group than in the GnRHa group (P < 0.05). Follicle to-Oocyte Index was significantly different between MPA + HMG group and GnRHa group (P < 0.001). No differences were found in the ovary response and numbers of mature oocytes, fertilized oocytes and viable embryos. The clinical pregnancy and live birth outcomes were similar between MPA + HMG group and GnRHa group, and these outcomes were independent of fresh or frozen embryo transfer in the GnRHa protocol group. There were no significant differences in the time to embryo transfer, medical cost and adverse effects. CONCLUSION: The number of oocytes retrieved and pregnancy outcomes after MPA + HMG protocol are similar to those after ultra-long GnRHa protocol in women with ovarian endometriosis. MPA + HMG protocol may be an alternative to ultra-long GnRHa protocol for IVF in ovary endometriosis patients. Trial registration The trial was registered in the Chinese Clinical Trial Registry (ChiCTR-INR-17010924) In conclusion, the administration of MPA in COH showed similar number of oocytes retrieved, no premature LH surge, and similar pregnancy and live birth outcomes in patients with advanced ovarian endometriosis undergoing IVF/ICSI as compared to the one-month long protocol. The use of MPA in COH appears to be promising although many questions remain to be elucidated, including the dose and time of progestin priming as well as its possible influence on the oocyte development potential and microenvironment. Given their good tolerability, few metabolic influence, and low cost, progestogens provide a novel alternative to the conventional protocol for patients with endometriosis.

The pregnancy outcomes of infertile women with polycystic ovary syndrome undergoing intrauterine insemination with different attempts of previous ovulation induction.

Background: Polycystic ovary syndrome (PCOS) is one of the most common reasons for infertility. The consensus of the treatment of infertile women with PCOS is ovulation induction (OI) for six to nine attempts before in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI). Nowadays, more attention was paid to a rising, noninvasive treatment, intrauterine insemination (IUI), as some experts claimed IUI could benefit PCOS patients with infertility. Our study means to investigate the outcomes of IUI for PCOS patients and if patients' previous OI cycles can be a predictive factor for IUI outcomes. Methods: A total of 1,086 PCOS patients was included and 1,868 IUI cycles were performed between January 2007 and July 2021 in the department of assisted reproduction in Shanghai Ninth People's Hospital. All included patients underwent IUI treatments with letrozole+human menopausal gonadotropin (LE+hMG) for ovarian stimulation. Results: The pregnancy outcomes were not associated with the attempts of failed OI cycles previously. Specifically, the clinical pregnancy rate was 21.14% for PCOS patients without previous OI cycles, 21.95% for PCOS patients with 1-2 previous OI cycles and 23.64% for PCOS patients with 3 or more previous OI cycles (p=0.507). The corresponding live birth rate was 16.64%, 18.06%, and 18.68%, respectively, of which the difference was not statistically significant (p=0.627). The cumulative rate per patient was 38.59% for clinical pregnancy and 31.03% for live birth, and approximately 98% of the pregnancies occurred in the first 3 cycles of IUI. Conclusion: PCOS women with different attempts of OI cycles had similar pregnancy outcomes after IUI, thus a history of repeated failures of OI treatments was not a predictive factor for the pregnancy outcomes in IUI cycles. Most pregnancies occurred in the first three cycles of IUI, so we strongly recommended three attempts of IUI for PCOS women before they switched to IVF/ICSI. Generally, IUI might be an assist for infertile women with PCOS before IVF/ICSI and might accelerate pregnancy for target women without invasive manipulations.

The impact of blastomere loss on pregnancy and neonatal outcomes of vitrified-warmed Day3 embryos in single embryo transfer cycles.

BACKGROUND: Blastomere loss is a common phenomenon that occurs following cryopreservation. To date, studies have drawn conflicting conclusions regarding the impact of blastomere loss on pregnancy outcomes. Besides, limited information is available concerning the neonatal safety of embryos with blastomere loss. In the present study, we aimed to investigate the impact of blastomere loss on pregnancy and neonatal outcomes of vitrified/warmed Day3 cleavage-stage embryos in single embryo transfer cycles. METHODS: This retrospective cohort study included all vitrified/warmed D3 cleavage-stage single frozen-thawed embryo transfer (FET) cycles between April 2015 and February 2021. We compared pregnancy and subsequent neonatal outcomes between the intact embryos group and the blastomere loss group in single FET cycles. RESULTS: A total of 6287 single FET cycles were included in the study, in which 5873 cycles were classified into the intact embryo group and 414 cycles were classified into the blastomere loss group. The outcomes of the blastomere loss group were significantly inferior to those of the intact embryo group, in terms of implantation/biochemical pregnancy/clinical pregnancy/ongoing pregnancy rate and live birth rate per embryo transfer cycle/per clinical pregnancy. Further binary logistic regression confirmed that blastomere loss was negatively associated with live birth. Moreover, the blastomere loss group presented with an elevated early miscarriage rate. The neonatal conditions were broadly similar between the two groups. Additionally, multiple binary logistic regression analysis demonstrated that primary infertility and intracytoplasmic sperm injection (ICSI) were common influencing factors of blastomere loss (aOR 1.447, 95% CI 1.038-2.019, P = 0.029; aOR: 1.388, 95% CI: 1.044-51.846, P = 0.024). CONCLUSIONS: The transfer of vitrified/warmed D3 embryos with blastomere loss is related to impaired embryo developmental potentials and reduced probabilities of conception. Moreover, even if the embryos with blastomere loss have implanted and reached clinical pregnancies, they present with a lower possibility of developing to live birth owing to a higher early miscarriage rate. However, once the embryos with blastomere loss result in a live birth, no adverse neonatal outcomes are observed. Primary infertility and ICSI were found to be risk factors for blastomere loss.

The Effect of Spontaneous LH Surges on Pregnancy Outcomes in Patients Undergoing Letrozole-HMG IUI: A Retrospective Analysis of 6,285 Cycles.

Background: To date, no consensus has been reached on whether to wait for spontaneous luteinizing hormone (LH) surge to occur or to trigger ovulation regardless of the presence of an LH surge for achieving higher success rate in intrauterine insemination (IUI) cycles. Therefore, we hope to investigate the effect of the presence of a spontaneous LH surge on pregnancy outcomes in letrozole-human menopausal gonadotropin (LE-HMG) IUI cycles. Methods: In this retrospective cohort study, a total of 6,285 LE-HMG IUI cycles were included between January 2010 and May 2021. Cycles were categorized into three groups: the trigger + LH surge group, the trigger only group, and the LH surge only group. The primary outcome measure was the clinical pregnancy rate. A logistic regression analysis was performed to explore other risk factors affecting the clinical pregnancy rate. Results: No significant differences were observed in biochemical pregnancy rate (P =0.640), clinical pregnancy rate (P =0.702), ongoing pregnancy rate (P =0.842), and live birth rate (P =0.951) among the three groups. The binary logistic regression analysis also confirmed that the existence of an LH surge was not associated with clinical pregnancy. There was a difference in ectopic pregnancy rates (P =0.045), but logistic regression showed that the presence of a spontaneous LH surge has no association with ectopic pregnancy. Nonetheless, patients with lead follicles within 18.1-20.0 mm/20.1-22.0 mm and a long duration of LE treatment were less likely to get ectopic pregnant compared with patients with 14.1-16.0 mm lead follicles and shorter LE treatment (OR: 0.142, 95% CI: 0.023-0.891, P =0.037; OR: 0.142, 95% CI: 0.022-0.903, P =0.039; OR: 0.445, 95% CI: 0.235-0.840, P = 0.013). Conclusions: The presence of a spontaneous LH surge in triggered LE-HMG IUI cycles does not appear to improve pregnancy rates. Thus, we suggest that waiting for an LH surge to occur is not necessary in triggered LE-HMG IUI cycles.

Comparison Between PPOS and GnRHa-Long Protocol in Clinical Outcome with the First IVF/ICSI Cycle: A Randomized Clinical Trial.

PURPOSE: To investigate whether progestin-primed ovarian stimulation (PPOS) can be an alternative as gonadotrophin-releasing hormone agonist (GnRHa) long protocol for infertile women with normal ovarian reserve during IVF/ICSI. METHODS: A prospective randomized controlled trial (RCT) including 257 patients was conducted between 1 August 2017 to 1 January 2018. Computerized randomization was performed to assign participants into two treatment groups at a 1:1 ratio: PPOS (130 patients) or GnRHa long protocol (127 patients) followed by their first IVF/ICSI with fresh/frozen embryo transfer. The primary outcome was the number of oocytes retrieved. Patients with normal ovarian reserve undergoing their first IVF/ICSI procedure were included. The embryological and clinical outcomes were measured. Only the first embryo transfer cycle was followed-up. RESULTS: Basic characteristics such as infertility duration, age, and body mass index (BMI) were comparable in both groups. No significant difference was found in the number (mean ± SD) oocytes retrieved [11.8 ± 6.5 for PPOS vs 11.3 ± 5.6 for GnRHa long protocol] or viable embryos [4.5 ± 3.0 for PPOS vs 4.2 ± 2.9 for GnRHa long protocol] between the groups. No patient from either group experienced a premature LH surge during the whole process of ovarian stimulation. Besides, there was no moderate or severe ovarian hyperstimulation syndrome during the ovarian stimulation in PPOS group while three patients suffered it in the GnRHa long protocol group. There was no significant difference in the clinical pregnancy rate of the first embryos transfer cycle between the two groups. CONCLUSION: PPOS in combination with embryo cryopreservation as an ovarian stimulation regimen was as effective as GnRHa long protocol during controlled ovarian stimulation (COH) under different endocrinal mechanisms. It can also achieve comparable embryological and clinical outcomes while reducing the incidence of moderate and severe ovarian hyperstimulation syndrome (OHSS) and HMG dosage. It can be an alternative of the treatments for infertile patients with normal ovarian reserve undergoing IVF as well as traditional protocols. TRIAL REGISTRATION NUMBER: ChiCTR-INR-17012089. TRIAL REGISTRATION DATE: Chictr.org.cn: 23 July 2017. DATE OF FIRST PATIENT'S ENROLLMENT: 1 August 2017.

Fertility and neonatal outcomes of embryos achieving blastulation on Day 7: are they of clinical value?

STUDY QUESTION: Is transferring embryos that achieve blastulation on Day 7 effective and safe? SUMMARY ANSWER: Embryos that achieve blastulation on Day 7 resulted in clinically relevant rates of clinical pregnancy (32.5%) and live birth (25.2%), and newborns have a similar risk of low birth weight, congenital malformations or early neonatal death compared with those derived from Days 5 and 6 blastocysts. WHAT IS KNOWN ALREADY: Potential advantages of blastocyst transfer over cleavage embryo transfer have led to a shift toward the former in IVF practice. However, published data about the fertility outcomes of transferring embryos with a delayed blastulation on Day 7 are scarce and controversial. Moreover, there are few data available on the neonatal outcomes of Day 7 blastocysts. As a result, the clinical value of Day 7 blastocysts is uncertain. STUDY DESIGN, SIZE, DURATION: This was a retrospective cohort study that included 2908 women undergoing frozen-thawed embryo transfer cycles of IVF/ICSI from January 2006 to May 2015, and reported on the 1518 live born infants from those cycles. PARTICIPANTS/MATERIALS, SETTING, METHODS: We used propensity score matching to compare the fertility outcomes of women undergoing Day-5, Day-6 and Day-7 vitrified embryo transfers in three matched comparisons (Day 5 vs Day 6, Day 5 vs Day 7 and Day 6 vs Day 7). We also compared neonatal outcomes among babies derived from Day-5, Day-6 and Day-7 vitrified embryo transfers. MAIN RESULTS AND THE ROLE OF CHANCE: We studied 922 Day-5, 1752 Day-6 and 234 Day-7 vitrified embryo transfers. Day-7 vitrified embryo transfers had significantly lower implantation, clinical pregnancy and live birth rates than both Day-5 (23.9 vs 49.9%, 31.7 vs 58.1% and 25.1 vs 46.5%, all P < 0.001, respectively) and Day-6 (24.7 vs 42.3%, 33.0 vs 53.2% and 25.6 vs 41.4%, all P < 0.001, respectively) vitrified embryo transfers. Assessment of babies showed no statistically significant difference in the rates of low birth weight, congenital malformations and early neonatal death among the 585, 869 and 64 babies born from Day-5, Day-6 and Day-7 vitrified embryo transfer groups, respectively. LIMITATIONS, REASONS FOR CAUTION: This was a single center retrospective study, and most of the neonatal data were extracted from parental questionnaires. Besides, the number of Day-7 vitrified embryo transfer cycles and babies born from these cycles was still limited, thus reducing the power of our study in assessing neonatal outcomes. In addition, only the morphologically poorer Day 3 embryos were extendedly cultured, and poorer blastocysts were qualified for vitrification on Day 7 than on Day 5 or 6, both of which might bias clinical pregnancy rates. WIDER IMPLICATIONS OF THE FINDINGS: Transfer of embryos that reach the blastocyst stage on Day 7 results in lower but still acceptable live birth rate, and seems to be safe for the offspring. Extension of the culture time in embryos that do not reach blastocyst stage by Day 6 should be assessed in randomized clinical trials. STUDY FUNDING/COMPETING INTEREST(S): This work was supported by the National Nature Science Foundation of China (Grant nos. 81771533, 81571397, 81571486, 31770989 and 81501319), the Nature Science Foundation of Shanghai (Grant nos. 15ZR1424900 and 1441196300), and the Foundation of Health and Family Planning Commission of Shanghai (Grant no. 201540237). B.W.M is supported by the National Health and Medical Research Council (NHMRC) Practitioner Fellowship (GNT1082548), B.W.M reports consultancy for ObsEva, Merck and Guerbet. TRIAL REGISTRATION NUMBER: Not applicable.

Purification and Characterization of Bacteriocin Produced by a Strain of Enterococcus faecalis TG2.

The aims of this study were to purify and characterize a bacteriocin produced by a strain of Enterococcus faecalis TG2 and to test the safety of the strain. In this work, the active peptide was purified through precipitation with 70% saturated ammonium sulfate, cation-exchange chromatography, and gel filtration. The specific activity of purified bacteriocin was 30,073.42 AU/mg of protein, which corresponded to a 33.34-fold increase. The molecular mass of the purified bacteriocin was 6.3362 kDa determined by LC-MS/MS. The ten amino acid of N-terminal was MTRSKKLNLR and the ten amino acid of C-terminal was ATGGAAGWKS. The activity of the bacteriocin was unaffected by pH 2-10 and thermostable but was sensitive to proteolytic enzymes. The antimicrobial activity of the bacteriocin was not affected by metal ions. Tween-20, Tween-80, Triton X-100, and EDTA did not affect the bacteriocin activity and SDS was able to increase the activity of bacteriocin. Bacteriocin activity was not lost after treatment by < 8% NaCl. Inhibitory spectrum of the bacteriocin showed a wide range of activities against other lactic acid bacteria, food-spoilage, and food-borne pathogens. Ent. faecalis TG2 was sensitive to tetracycline and erythromycin but resistant to ampicillin, gentamicin, kanamycin, and chloramphenicol. Results from PCR indicated that Ent. faecalis TG2 did not harbor any virulence genes. The study suggests that Ent. faecalis TG2 and its bacteriocin might be used as bio-preservatives in food products.