Ovarian Stimulation in Assisted Reproductive Technology Cycles for Varied Patient Profiles: An Indian Perspective.

Controlled ovarian stimulation has been an integral part of in vitro fertilisation (IVF) treatment cycles. Availability of different gonadotropins for ovarian stimulation and gonadotropin releasing hormone (GnRH) analogues for prevention of premature rise of leutinising hormone during follicular phase offer an opportunity to utilise them for a successful outcome in women with different subsets of ovarian response. Further, use of GnRH agonist as an alternative for human chorionic gonadotropin improves safety of ovarian stimulation in hyper-responders. Mild ovarian stimulation protocols have emerged as an alternative to conventional protocols in the recent years. Individualisation plays an important role in improving safety of IVF in hyper-responders while efforts continue to improve efficacy in poor responders. Some of the follicular and peri-ovulatory phase interventions may be associated with negative impact on the luteal phase and segmentalisation of the treatment with frozen embryo transfer may be an effective strategy in such a clinical scenario. This narrative review looks at the available evidence on various aspects of ovarian stimulation strategies and their consequences. In addition, it provides a concise summary of the evidence that has emerged from India on various aspects of ovarian stimulation.

Outcomes and Recommendations of an Indian Expert Panel for Improved Practice in Controlled Ovarian Stimulation for Assisted Reproductive Technology.

Purpose. To improve success of in vitro fertilization (IVF), assisted reproductive technology (ART) experts addressed four questions. What is optimum oocytes number leading to highest live birth rate (LBR)? Are cohort size and embryo quality correlated? Does gonadotropin type affect oocyte yield? Should "freeze-all" policy be adopted in cycles with progesterone >1.5 ng/mL on day of human chorionic gonadotropin (hCG) administration? Methods. Electronic database search included ten studies on which panel gave opinions for improving current practice in controlled ovarian stimulation for ART. Results. Strong association existed between retrieved oocytes number (RON) and LBRs. RON impacted likelihood of ovarian hyperstimulation syndrome (OHSS). Embryo euploidy decreased with age, not with cohort size. Progesterone > 1.5 ng/dL did not impair cycle outcomes in patients with high cohorts and showed disparate results on day of hCG administration. Conclusions. Ovarian stimulation should be designed to retrieve 10-15 oocytes/treatment. Accurate dosage, gonadotropin type, should be selected as per prediction markers of ovarian response. Gonadotropin-releasing hormone (GnRH) antagonist based protocols are advised to avoid OHSS. Cumulative pregnancy rate was most relevant pregnancy endpoint in ART. Cycles with serum progesterone ≥1.5 ng/dL on day of hCG administration should not adopt "freeze-all" policy. Further research is needed due to lack of data availability on progesterone threshold or index.

Scheduling cycles with gonadotropin-releasing hormone antagonist protocol in in vitro fertilization: Is there a scope in batch in vitro fertilization?

In India, a practice of "Batch in vitro fertilization (IVF)" has evolved in many infertility centers in an effort to align infertility management with logistics. A "Batch IVF" is an approach where the menstrual cycles of multiple women are programmed, such that they can undergo all the processes; from stimulation until embryo transfer about the same time. In "Batch IVF", the day for initiating stimulation is calculated retrospectively from the day the visiting embryologist is available at the clinic (day of ovum pick-up). Aligning the cycles of multiple women with steroids followed by down regulation with long gonadotropin-releasing hormone agonist (GnRH-A) is one of the currently employed methods for batching. There is sufficient evidence on scheduling cycles with steroids in GnRH-An protocol without compromising on the outcome. The objective of this paper is to provide evidence-based clinical concept on scheduling cycles in "Batch IVF" setup with GnRH-An protocol through literature review.

Luteinizing hormone and follicle stimulating hormone synergy: A review of role in controlled ovarian hyper-stimulation.

Luteinizing hormone (LH) in synergy with follicle stimulating hormone (FSH) stimulates normal follicular growth and ovulation. FSH is frequently used in assisted reproductive technology (ART). Recent studies have facilitated better understanding on the complementary role of the LH to FSH in regulation of the follicle; however, role of LH in stimulation of follicle, optimal dosage of LH in stimulation and its importance in advanced aged patients has been a topic of discussion among medical fraternity. Though the administration of exogenous LH with FSH is obligatory for controlled ovarian stimulation in patients with hypogonadotropic hypogonadism, there is still a paucity of information of its usage in other patient population. In this review we looked in to the multiple roles that LH plays complementary to FSH to better understand the LH requirement in patients undergoing ART.

The in vitro effect of benzo[a]pyrene on human sperm hyperactivation and acrosome reaction.

OBJECTIVE: To evaluate the in vitro effect of benzo[a]pyrene on sperm hyperactivation and acrosome status in normozoospermic semen samples of nonsmokers analyzed by computer-assisted semen analysis (CASA). DESIGN: Experimental in vitro study. SETTING: Andrology laboratory. PATIENT(S): Thirteen proven fertile, normozoospermic, and nonsmoking men. INTERVENTION(S): Spermatozoa were washed free of seminal plasma and were treated with different concentrations of benzo[a]pyrene and compared with controls treated with medium alone. The benzo[a]pyrene concentrations were: 100, 50, 25, and 12.5 microg/mL. MAIN OUTCOME MEASURE(S): Effect of varying concentrations of benzo[a]pyrene on sperm hyperactivation and acrosomal reaction. RESULT(S): A statistically significant increase in sperm hyperactivation was observed in presence of benzo[a]pyrene at concentrations of >or=50 microg/mL. The result of the acrosome halo test showed that concentrations of benzo[a]pyrene >or=25 microg/mL statistically significantly decreased the percentage of halo formation, indicating an inappropriate (false) acrosome reaction. CONCLUSION(S): Benzo[a]pyrene statistically significantly affected sperm functional competence as evidenced by increased hyperactivation as well as premature acrosomal reaction.