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Ultrasonographic Monitoring of Follicle Growth in Controlled Ovarian Hyperstimulation
Published in Arianna D'Angelo, Nazar N. Amso, Ultrasound in Assisted Reproduction and Early Pregnancy, 2020
Controlled ovarian hyperstimulation (COH) is achieved by daily subcutaneous injections of recombinant or urinary gonadotropins (Gn). The dose is individualized, and the aim is to recruit 5–15 follicles. USS is used to assess the number and average diameter of the developing follicles for timing of egg retrieval. The estimated pregnancy rate per cycle using standard COH is approximately 30% [2], but when using minimal ovarian stimulation, the pregnancy rate per cycle is lower, approximately 10% [3]. This is why the accuracy of follicular ultrasound monitoring is very important for the ultimate outcome. In addition, ovaries might overrespond to the stimulation protocol, causing ovarian hyperstimulation syndrome (OHSS), which can be a life-threatening condition [4], and hence, the importance of having a reliable and secure tool to monitor superovulation. Martins et al. [5] performed a literature search up to April 2013 for randomized controlled trials (RCTs) on this topic. Studies that compared different methods for monitoring COH, including ultrasound assessment of follicles (alone or combined with hormonal assessment), in at least one group were included in the meta-analysis. The objective of the meta-analysis was to evaluate the efficacy and safety of monitoring COH using ultrasonography. Of the 1515 records found, only six studies fulfilled the inclusion criteria and were analyzed.
SBA Questions
Published in Justin C. Konje, Complete Revision Guide for MRCOG Part 2, 2019
A 30-year-old woman is undergoing controlled ovarian hyperstimulation for in vitro fertilization. What factor will be associated with a decreased risk of ovarian hyperstimulation syndrome (OHSS) in this woman?Her ageHigh antral follicle countLow AMHKnown case of PCOSPrevious OHSS
Oocyte retrieval and selection
Published in David K. Gardner, Ariel Weissman, Colin M. Howles, Zeev Shoham, Textbook of Assisted Reproductive Techniques, 2017
Laura F. Rienzi, Filippo M. Ubaldi
On the basis of these findings, the “FSH window” concept has been introduced, suggesting the importance of the duration of FSH elevation above the threshold level rather than the height of the elevation of FSH for single dominant follicle selection (6, 7, 12). The different stimulation protocols used for controlled ovarian hyperstimulation are based on the concept of widening the FSH window with the use of exogenous gonadotropins from the early follicular phase to the day of human chorionic gonadotropin (hCG) administration. Over the last 25 years different stimulation protocols have been proposed. Easier stimulation regimens such as clomiphene citrate (CC) alone or in combination with human menopausal gonadotropin (hMG) and urinary FSH were gradually abandoned in favor of protocols where GnRH agonists (GnRHas) are used in combination with gonadotropins. These lengthy protocols, which have been for decades the most widely used treatments for ovarian stimulation, allowed us to manage the activity of in vitro fertilization (IVF) centers more easily, enabled lower cancellation rates, and raised the number of preovulatory follicles, the number of oocytes retrieved, and the number of good-quality embryos for transfer, thus leading to increased pregnancy rates (13). However, these regimens are not free from complications and costs for the patients. The clinical introduction of GnRH antagonists in IVF (14–16), with their immediate suppression of pituitary function, allows the administration of low doses of gonadotropins from the mid-follicular phase, resulting in more “patient-friendly” stimulation protocols (17, 18) with fewer days of stimulation, lower amounts of gonadotropins administered, and fewer oocytes retrieved. However, if these milder protocols may improve patients compliance, reducing the burden of IVF on the couple, the question that remains to be answered is whether the reduced number of oocytes obtained after mild protocols may impair the clinical outcome when calculated cumulatively (including cryopreservation cycles).
The relationship between good quality embryo rates and IVF outcomes/embryo transfer policies in extended embryo culture
Published in Journal of Obstetrics and Gynaecology, 2022
Ayten Türkkanı, Cemile Merve Seymen, İnci Kahyaoğlu, İskender Kaplanoğlu, A. Şebnem İlhan, Çiğdem Elmas, Serdar Dilbaz
Controlled ovarian hyperstimulation was performed using long GnRH agonist, microdose flare or antagonist protocols. The type of gonadotropin used was either pure recombinant follicle-stimulating hormone (FSH) or human menopausal gonadotropin (hMG). Gonadotropin doses were individualised for each patient. Cycles were monitored by serial transvaginal ultrasound evaluation and serum oestradiol levels. Recombinant human chorionic gonadotropin (hCG) (Ovitrelle, Serono, Istanbul, Turkey) was administered when at least three follicles showed a mean diameter of 17 mm. Oocyte pick up (OPU) procedures were performed by transvaginal ultrasound-guided aspiration 35.5–36 h after the hCG injection. Following retrieval, cumulus oophorus was removed from oocytes by incubation in a solution containing hyaluronidase (Vitrolife, Gothenburg, Sweden). The remaining cells were removed mechanically using commercial denuding pipettes. Denuded oocytes were cultured in G-IVF (Vitrolife, Gothenburg, Sweden) medium at 37 °C in a humidified atmosphere of 5% CO2–95% air, until used for ICSI.
Is low anti-Mullerian hormone (AMH) level a risk factor of miscarriage in women <37 years old undergoing in vitro fertilization (IVF)?
Published in Human Fertility, 2022
Anne-Sophie Cornille, Clémence Sapet, Arnaud Reignier, Florence Leperlier, Paul Barrière, Pascal Caillet, Thomas Fréour, Tiphaine Lefebvre
An antagonist protocol was used for Controlled Ovarian Hyperstimulation (COH). The starting dose of gonadotropins was individually adjusted according to: Body Mass Index (BMI), AMH level, AFC or the ovarian response to previous COH. Hormonal and ultrasound monitoring was performed during treatment. When conditions were favourable (at least 3 follicles > 17mm), ovulation was triggered by recombinant hCG (Ovitrelle© 1 injection of 250 µg). Ovum pickup was performed 36 hours later. Embryos were cultured for 5–6 days up to blastocyst stage for all patients. One or 2 blastocysts were transferred, and supernumerary embryos were vitrified. Luteal phase supplementation with vaginal progesterone (400 mg/day) was performed from ovum pickup to pregnancy test 11 days after embryo transfer.
Successful live birth after in vitro maturation treatment in a patient with autoimmune premature ovarian failure: a case report and review of the literature
Published in Gynecological Endocrinology, 2021
Lucie Chansel-Debordeaux, Elisabeth Rault, Chloé Depuydt, Volcy Soula, Claude Hocké, Clément Jimenez, Hélène Creux, Aline Papaxanthos-Roche
Since controlled ovarian hyperstimulation alone gives poor results in such a situation, various approaches have been used to increase pregnancy rates, including immunosuppressive therapy and DHEA supplementation, with or without IVF. Some studies showed the value of corticosteroids for improving the pregnancy success rate in a subset of patients with previous IVF failures and high serum AOA levels [33,50]. Indeed, decreasing the high, endogenous, ineffective FSH, by gonadotropin releasing hormone agonist associated to controlled ovarian hyperstimulation and corticosteroids were sometimes effective in generating conceptions in patients with POF [51]. The release of the FSH receptors occupancy from the endogenous FSH, may give way to receptor stimulation by exogenous FSH, combined with amelioration of the autoimmune disturbance by glucocorticoids cotreatment. The mechanism of action of corticosteroids is thought to involve a reduction in perifollicular inflammatory macrophages around follicles, which can then restore folliculogenesis in dormant small follicles [15]. In another study, corticosteroids did not influence ovarian responsiveness to gonadotropins in patients with POF [52]. Some studies noted higher pregnancy rates with DHEA supplementation in patients with diminished ovarian function [53,54]. Estrogens have also proven beneficial for the recovery of ovarian function via the restoration of receptor sensitivity to gonadotropins, thus promoting folliculogenesis [9]. However, to date no treatment for autoimmune oophoritis has demonstrated efficacy and safety in prospective randomized placebo-controlled studies.