08-blockeel_Opmaak 1 20/09/12 09:47 Pagina 203 FVV inObGyn, 2012, 4 (3): 203-212 PhD Summary Optimisation of the follicular phase in IVF/ICSI C. blOCkeel1 Promotor:P. DeVrOey1 1Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, B-1090 Brussels, Belgium. Correspondence at: [email protected] Abstract In reproductive medicine, the aim is to establish an optimal balance between cost-effectiveness, success rate and safety for the patient. In this thesis, a series of clinical studies are presented that all revolve around the optimisation of ovarian stimulation with GnRH antagonist co-treatment. Basal hormonal levels at the start of ovarian stimulation are mandatory to obtain acceptable pregnancy rates. In view of this, we focused on the impact of cycle day 2 prog- esterone levels on treatment outcome. By interfering in the early follicular phase, we tried to synchronise the fol- licular cohort and to increase the number of retrieved oocytes. Innovative treatment protocols based on GnRH antagonists should lead to a more flexible and better controlled schedule of oocyte retrievals. The inability to program the start of gonadotrophin stimulation and hence to minimise weekend oocyte retrievals is a major impediment to the widespread implementation of the GnRH antagonist protocol in fertility clinics. Because treatment schedule is important both for the patients, who wish to undergo reproductive treatment at their own convenience, and for the ART clinic, to organise the workload, we attempted to bring the schedule of egg retrievals in a GnRH antagonist protocol under improved control. Another important aim of our clinical research was to diminish patient discomfort and reduce side effects by a simplification of GnRH antagonist ovarian stimulation protocols. We also focused on significant reduction of FSH consumption by substitution of FSH by low dosages of hCG during the mid-late follicular phase, without impairing outcome in terms of oocyte yield and ongoing pregnancy rate or live birth rate. Key words:GnRH antagonist, follicular phase, IVF, ICSI, reproductive endocrinology, scheduling. Introduction were used for the prevention of a premature lH rise during ovarian stimulation (Fleming et al., 1982; The introduction of ovarian stimulation is an impor- Porter et al., 1984). Gonadotrophin-releasing tant milestone in the history of assisted reproductive hormone (GnrH) antagonists were introduced for technologies (ArT), since this practice led to multi- ovarian stimulation in ArT during the last decade. ple follicular growth, the retrieval of several oocytes Antagonists are associated with less side-effects and consequently more embryos (blackwell et al., in comparison with the GnrH agonists, because of 1973; Dierschke et al., 1970). numerous stimulation their different mode of pharmacological action on regimens have been described, ranging from no the pituitary. The antagonistic analogue has an stimulation (natural cycles), to minimal stimulation immediate action and thus can be administered (clomiphene citrate) or mild stimulation (sequential precisely at the moment that suppression of a lH treatment with clomiphene citrate and low dose surge is needed, resulting in a shorter duration of exogenous gonadotrophins), to aggressive stimula- stimulation and absence of side-effects caused by tion (high dose exogenous gonadotrophins, alone or profound hypo-estrogenemia. inadvertent adminis- in combination with a gonadotrophin-releasing tration of the GnrH analogue in early pregnancy can hormone (GnrH) agonist or antagonist). each be avoided as the GnrH antagonist is administered approach has its advantages, disadvantages, and in the mid-follicular phase (Tarlatzis et al., 2006). applications. Since the early 1980s, GnrH agonists nevertheless, GnrH antagonists offer less flexibility 203 08-blockeel_Opmaak 1 20/09/12 09:47 Pagina 204 regarding cycle programming compared with GnrH be proposed as a planning tool for follicular cohort agonists (Tarlatzis et al., 2006). synchrony and scheduling of ArT treatment in all Patients undergoing iVF/iVSi frequently experi- patients, including those with normal serum proges- ence a substantial burden and psychological distress. terone levels on day 2 of the treatment cycle. The This burden is largely accounted for by two factors: purpose of this next prospective randomised trial length of treatment and side effects (Devroey et al., was to study the impact of a three-day course of 2009). The patients’ experience may be improved GnrH antagonist pretreatment on the number of through the use of GnrH antagonists instead of COCs (blockeel et al., 2011c). GnrH agonists. Apart from the aim to improve pregnancy rates, There appears to be no clinically significant dif- innovative treatment protocols based on GnrH ference in terms of live birth rate between GnrH an- antagonists should lead to a more flexible and better tagonists and agonists: two meta-analyses comparing controlled schedule of oocyte retrievals, such as in the two classes of GnrH analogues found almost the long GnrH agonist protocol. The inability to identical odds ratios (0,82 - 0,86) for the probability program the start of gonadotrophin stimulation and of live birth, although the difference was statistically hence to minimise weekend oocyte retrievals is a significant in one analysis (Al-inany et al., 2006) and major impediment to the widespread implementation not in another (kolibianakis et al., 2006). recently, of the GnrH antagonist protocol in fertility clinics. a systematic review and meta-analysis showed no because treatment schedule is important both for the difference in live birth rates between GnrH antago- patients, who wish to undergo reproductive treat- nists and agonists (Al-inany et al., 2011). ment at their own convenience, and for the ArT regarding secondary outcomes, both meta- clinic, to organise the workload, we attempted to analyses found shorter duration of GnrH analogue bring the schedule of egg retrievals in a GnrH an- administration, decreased gonadotrophin require- tagonist protocol under improved control. Oral con- ments and lower incidence of ovarian hyperstimula- traceptive pill (OCP) pretreatment is increasingly tion syndrome (OHSS) in the antagonist group. On being abandoned as a planning tool, since this results the contrary, significantly more cumulus-oocyte in significantly lower pregnancy rates (Griesinger et complexes were retrieved in the agonist as compared al., 2010). it has been hypothesised that the gestagen with the antagonist group (Al-inany et al., 2006; component of the OCP could exert a negative impact kolibianakis et al., 2006). on endometrial receptivity in the subsequent cycle. More than 20 different GnrH antagonist Alternatively, low endogenous lH levels after OCP protocols have been reported, which reflects an pretreatment might impair oocyte competence or ongoing process of refinement and improvement endometrial receptivity when ovarian stimulation (kolibiniakis et al., 2006; Tarlatzis et al., 2006; is performed with recombinant FSH without lH Devroey et al., 2009). in GnrH antagonist cycles (Griesinger et al., Attempts to improve the outcome of assisted 2008). reproductive technology (ArT) programs in terms The aim of this study was to prospectively analyse of improving patient friendliness, reducing the the ability to control the scheduling of GnrH antag- incidence of potential complications such as cyst onist cycles by the administration of estradiol valer- formation and development of the ovarian hyper- ate during the luteo-follicular transition period prior stimulation syndrome (OHSS), and cutting the to the initiation of ovarian stimulation (blockeel et global cost of ArT, have led to a growing interest in al., 2012, rbMOnline). GnrH-antagonist protocols. Scarce information is currently available regard- basal hormonal levels at the start of ovarian ing the endocrine profile of the follicular phase stimulation are mandatory to obtain acceptable preg- during the so-called ‘mild ovarian stimulation’ nancy rates. elevated progesterone levels at the start protocols (Hohmann et al., 2003). We conducted a of ovarian stimulation in patients treated with rFSH randomised, controlled trial to compareendocrine and GnrH antagonists are associated with reduced parameters and follicular development in iVF/iCSi pregnancy rates (kolibianakis et al., 2004). How- cyclesduring which stimulation was started either on ever, the incidence of this condition has been poorly cycle day 2 or 5, and to evaluate the clinical appli- documented. The purpose of our cohort study was cability of a deferred start of gonadotrophin stimu- to prospectively compare the ongoing pregnancy lation. The hypothesis was that when the start of rates in patients with normal and elevated proges- gonadotrophin is postponed until cycle day 5, com- terone levels on day 2 of the treatment cycle in a bined with an early start of the GnrH antagonist, a GnrH antagonist protocol (blockeel et al., 2011b). mild ovarian response would occur, characterised by in line with this trial, we subsequently hypothe- a moderate estradiol rise, whilst preserving lH sised that pretreatment with GnrH antagonists could suppression (blockeel et al., 2011d). 204 FVV inObGyn 08-blockeel_Opmaak 1 20/09/12 09:47 Pagina 205 For many years, FSH was considered the only Methods stimulatory hormone needed for ovulation induction, acting through specific receptors on granulosa cells All the studies were conducted in the period between of ovarian follicles. in a GnrH agonist protocol, it 2007-2011 at the Centre of reproductive Medicine was demonstrated that the administration of low of UZ brussel. All patients with primary or second- doses of hCG (100-400 iU/day) can be successfully ary infertility were included. A complete hormonal applied in patients undergoing ArT as a substitute investigation with FSH, lH, e, testosterone, delta4- 2 for recombinant FSH in the final days of ovarian androstendione, prolactine, DHeAS, TSH, T3 and stimulation (Filicori et al., 2002a). in GnrH T4 was performed. A complete serological screening antagonist cycles, mid-late follicular phase FSH was added (Hepatitis b, C, HiV, Syphilis, CMV, substitution by hCG, rather than supplementation, Toxoplasmosis and rubella) before being included. has been reported in a small cohort study, but this before entering the study, all patients underwent a approach has not been investigated in a randomised complete pelvic examination and an ultrasound scan. controlled fashion (kenigsberg et al., 2006). Taking ethical approval was obtained by the ethical into account the more profound suppression of Committee of the Universitair Ziekenhuis brussel. endogenous lH-levels by a GnrH-antagonist as in case of a rCT, randomisation was performed at compared to a GnrH-agonist, we conducted a the outpatient clinic, when the results of the pre- preliminary study to explore whether low doses of treatment hormonal analyses were discussed with the hCG (200 iU/d) have similar potential to stimulate patient. A computer-generated list was used for ran- follicular development and yield satisfactory domisation, concealed to the recruiting nurse who ongoing pregnancy rates in the absence of FSH made the decision about allocation by using a series (blockeel et al., 2009). As a continuation of this trial, of consecutively numbered sealed opaque envelopes. we aimed to assess the influence of the administra- The treating physicians remained blind to the inter- tion of low dose hCG in the late follicular phase vention group of each patient throughout the ovarian before final oocyte maturation on endometrium stimulation cycle, but the study nurses and the pa- histology; we studied the morphological pattern and tients were aware of treatment group allocation. gene expression profile of human endometrium on each patient gave written informed consent and was the day of oocyte retrieval (blockeel et al., 2011a). enrolled in a study only once. Fig. 1.— randomised controlled trial with GnrH antagonist pretreatment in the study group (blockeel et al., 2011) OPTiMiSATiOn OF THe FOlliCUlAr PHASe – blOCkeel 205 08-blockeel_Opmaak 1 20/09/12 09:47 Pagina 206 Fig. 2.— randomised controlled trial with estradiol valerate pretreatment in the study group (blockeel et al., 2012) Multifollicular ovarian stimulation was triggered by the administration of 10,000 iU hCG (Pregnyl®, MSD, Oss, The netherlands), as Since protocols for ovarian stimulation differ signif- soon as three follicles of 17 mm diameter were icantly in the presented studies, the methodology is visualised on ultrasonography (kolibianakis et al., described in Figures 1 to 4. Final oocyte maturation 2004). Cumulus-oocyte-complexes (COC) were Fig. 3.— randomised controlled trial with start of stimulation on cycle day 5 in the study group (blockeel et al., 2011) 206 FVV inObGyn 08-blockeel_Opmaak 1 20/09/12 09:47 Pagina 207 Fig. 4.— randomised controlled trial with low dose hCG as a substitution of FSH in the late follicular phase (blockeel et al., 2009) collected 36 hours after Pregnyl® administration. Results luteal phase support consisted of 600 mg of vagi- nally administered micronised natural progesterone GnRH antagonist pretreatment in case of elevated (Utrogestan®, besins international, Paris, France) progesterone per day. To assess the treatment outcome, serum hCG was measured 14 and 17 days after oocyte re- A total of 484 patients participated in this prospec- trieval. HCG levels above 20 iU/l were indicative tive cohort study. Abnormal progesterone levels for occurrence of a pregnancy. on day 2 of the cycle were recorded in 30 out of 484patients (6.2%). Subsequent administration of a Embryo culture, evaluation and embryo transfer GnrH antagonist on three consecutive days in the high progesterone group resulted in the normaliza- in the trials, conventional iVF or iCSi was per- tion of progesterone values in all patients (Fig. 1). formed. Procedures for intracytoplasmic sperm in- Serum hormone levels of FSH, lH, e and prog- 2 jection were carried out as described by Van landuyt esterone on the day of hCG trigger administration et al. (2005). normal fertilisation was checked on were similar in both treatment groups. The preg- day 1. embryo quality was assessed daily from day nancy rates per started cycle, per oocyte pick-up and 2 onwards until the moment of transfer or cryop- per embryo transfer were not significantly different reservation (in case of good-quality spare embryos), in both treatment groups (Table i). as described by Papanikolaou et al. (2005a,b). The embryo quality on day 5 was assessed according to GnRH antagonist pretreatment in case of normal the criteria of Gardner and Schoolcraft (1999). All progesterone transfers were single embryo transfers on day 5, ex- cept for the prospective cohort trial (blockeel et al., A total of 69 patients were randomly assigned to 2011b) and the D2 versus D5 trial, where day 3 em- either the control group (n = 36) or the pretreatment bryo transfer was also allowed. group (n = 33). The groups did not significantly dif- OPTiMiSATiOn OF THe FOlliCUlAr PHASe – blOCkeel 207 08-blockeel_Opmaak 1 20/09/12 09:47 Pagina 208 Table I. — GnrH antagonist pretreatment in case of elevated progesterone: clinical outcome measures (blockeel et al., 2011b). Normal P Elevated P p value (P < 1.5 ng/mL) (P > 1.5 ng/mL) Positive hCG Per started cycle % (n) 31.9 (145/454) 23.3 (7/30) 0.33 Per pickup % (n) 32.1 (145/452) 26.9 (7/26) 0.58 Per embryo transfer % (n) 36.1 (145/402) 29.2 (7/24) 0.49 Outcome for patients with positive hCG test biochemical pregnancy % (n) 10.3 (15/145) 42.9 (3/7) 0.01 Miscarriage % (n) 9.7 (14/145) 0.0 (0/7) 0.38 ectopic pregnancy % (n) 2.8 (4/145) 0.0 (0/7) 0.66 Ongoing pregnancy % (n) 77.2 (112/145) 57.1 (4/7) 0.22 fer with regard to baseline and demographic charac- With regard to the outcome of ovarian stimulation teristics, such as age, bMi, basal FSH, antral follicle in both groups, a longer duration of stimulation was count, number of previous iVF/iCSi trials and indi- observed in the pretreatment group [9.6 (SD 1.4) cation for infertility treatment. days versus 8.6 (SD 1.5) days in the control group The duration of hormonal stimulation (8.8 vs (p = 0.004)]. The number of COCs obtained at re- 8.9d) and total dose of gonadotropins (1568.2 iU vs trieval was similar in both groups. The proportion of 1499.6 iU) were similar in the two groups. The num- patients undergoing an oocyte retrieval during the ber of COCs retrieved was 9.9 (SD 4.9) and 12.8 weekend was significantly lower in the pretreatment (SD 7.8) in the control and pretreatment group, re- group (1/37) compared to the control group (8/39), spectively, with a between group difference of 2.9 with an absolute between-group difference of and 95% confidence limits of -0.2 to 6.0 (p = 0.067). -17.8% (95% confidence interval -31.5% to -4.1%, Among the patients who had oocyte retrieval (36 p = 0.029). Only one oocyte retrieval occurred on a control vs 31 women in the pretreatment group) the Saturday in the pretreatment group (Fig. 5). crude and adjusted between-group differences for The ongoing pregnancy rates per started cycle the number of COCs retrieved were 3.7 (0.7 to 6.7; were similar in the pretreatment group (16/42 or p = 0.016) and 3.9 (0.9 to 7.0; p = 0.012), respec- 38.1%) and the control group (16/44 or 36.4%), tively. Ongoing pregnancy rates per started cycle, between-group difference -1.7%, p = 0.868). per oocyte retrieval and per embryo transfer were similar in both groups (Table ii). Start of ovarian stimulation on day 2 or day 5 of the cycle Estradiol valerate pretreatment Overall duration of rFSH administration (days of A total of 86 patients were randomly assigned to stimulation) in the study group was significantly either the control group or the pretreatment group lower than in the control group. The total dose of (Fig.2). Demographic characteristics did not differ rFSH consumed was significantly lower in the study significantly between both groups. group: 1,364 iU (SD 226) versus 1,177 iU (SD 295), Table II. — GnrH antagonist pretreatment in case of normal progesterone (blockeel et al., 2011c). Control group Pretreatment group P - value Starting dose of rFSH (iU) 177.7 ± 32.3 166.9 ± 22.9 0.125 Days of rFSH stimulation 8.8 ± 1.7 8.8 ± 1.4 1.000 number of COCs* 9.9 ± 4.9 13.6 ± 7.3 0.016 Ongoing pregnancy rate per started cycle % (n) 33.3% (12/36) 42.4% (14/33) 0.596 * number of COCs among patients who underwent oocyte retrieval. 208 FVV inObGyn 08-blockeel_Opmaak 1 20/09/12 09:47 Pagina 209 Fig. 5.— Oocyte retrieval by day in the estradiol valerate pretreatment group and the control group (blockeel et al., 2012) p < 0.01. The number of COCs obtained at retrieval Influence on the endometrium of low dose hCG was similar in both groups. The fertilisation rate, the in the late follicular phase implantation rate, the pregnancy rate and abortion rate were comparable in both groups. The ongoing A total of 35 patients were randomly assigned to pregnancy rate per started cycle was 28% (10 out of either the study or the control group. All patients un- 36 patients in the control group and 25% (10 out of derwent an endometrial biopsy on the day of oocyte 40 patients) in the study group (P = 0.78). Serum retrieval. There was no difference in both groups in hormone levels were measured on day 2, day 6 and terms of histological dating of the endometrium on day 8 of the cycle, and immediately before triggering the day of oocyte retrieval. Gene expression analysis final oocyte maturation. Follicular phase patterns of was performed on 5 non-pregnant patients from the both gonadotropin and steroid levels did not demon- hCG-group and 5 non-pregnant patients from the strate clear differences between both treatment control group. it showed a significant differential groups, except for the serum estradiol and FSH level expression of 65 probe sets between the hCG- and being significantly higher and the serum lH level the rFSH-group, with 21 upregulated and 44 down- being significantly lower on day 6 of the cycle in the regulated in the hCG-group. Unsupervised principal control group. Also, lH levels appeared significantly component analysis (PCA) with GeneSpring GX 7.3 higher in the study group at the time of hCG. was applied to reduce the multidimensional gene expression data into three dimensions. it showed a Low dose hCG in the late follicular phase heterogenous expression pattern with no specific clusters for both study groups. A total of 70 patients were randomly assigned to either the study or the control group (Fig. 5). Overall Discussion treatment duration (days of stimulation) did not sig- nificantly differ. Obviously, the duration of rFSH ad- A key step forward in developing strategies for iVF ministration in the hCG-group was significantly stimulation was the introduction of GnrH antago- lower than in the control group. HCG was adminis- nists. in contrast to GnrH agonists that rely on pitu- tered in the hCG-group for 2.3 ± 1.4 days. The total itary desensitisation, GnrH antagonists cause dose of rFSH consumed was significantly lower in immediate gonadotrophin suppression by competi- the hCG group: 1273 (SD 260) versus 1617(SD tive occupancy of the GnrH receptor. As stated in 280), p < 0.001. The number of COCs obtained at the introduction, GnrH antagonist regimens yield retrieval was similar in both groups. The fertilisation shorter stimulation cycles, resulting in fewer rate, the implantation rate, the pregnancy rate and injections and therefore a substantial decrease of the abortion rate were comparable in both groups patients’ burden (Devroey et al., 2009). Moreover, (Tableiii). side-effects and risk of OHSS and cycle cancellation OPTiMiSATiOn OF THe FOlliCUlAr PHASe – blOCkeel 209 08-blockeel_Opmaak 1 20/09/12 09:47 Pagina 210 Table III. — low dose hCG in the late follicular phase: cycle outcome measures(blockeel et al., 2009). rFSH-group Low-dose hCG P value for Mean (SD) group between-group Mean (SD) difference Total dose of rFSH, iU 1617 (280) 1273 (260) < 0.001 Overall treatment duration, days 8.2 (1.6) 8.7 (1.6) 0.19 rec FSH duration, days 8.2 (1.6) 6.4 (1.3) < 0.001 hCG duration, days 0 2.3 (1.4) < 0.001 number of COCs 12.3 (5.8) 11.1 (5.2) 0.40 number of ongoing pregnancies n(%) Per started cycle 10 / 35 (29%) 13 / 35 (37%) 0.45 Per pickup 10 / 32 (31%) 13 / 29 (45%) 0.28 Per embryo transfer 10 / 29 (35%) 13 / 27 (48%) 0.30 are reduced in antagonist cycles (kolibianakis et al., patient-friendly modified protocol is associated with 2006; Heijnen et al., 2007; Al-inany et al., 2011). a small financial cost increment of approximately in the work presented in this thesis, i have aimed 110 euros per cycle. Another possible drawback of to define new strategies for ArT cycles, stimulated this pretreatment protocol is the addition of three with GnrH antagonist co-treatment. The focus of subcutaneous injections to the patient. these strategies was to improve the balance between Pretreatment with estradiol valerate reduces the treatment efficacy and burden. in the first part of the proportion of oocyte retrievals during weekend days, work, i focused on the luteo-follicular transition without affecting the number of COCs or ongoing phase and early follicular phase, whereas in the sec- pregnancy rates. The clinical potential of this short ond part, i tried to optimise the mid-late follicular and patient-friendly protocol is associated with a phase. smaller financial cost increment than the GnrH an- tagonist pretreatment protocol, besides the absence Early Follicular Phase of supplementary injections in the estradiol pretreat- ment protocol. Using this protocol, we are able to Progesterone levels at the start of ovarian stimulation schedule the oocyte retrievals without changing the in patients treated with rFSH and GnrH antagonists criteria for final oocyte maturation, as prolongation are of crucial importance. Although the occurrence of the follicular phase by delaying the administration has been poorly documented, elevated progesterone of hCG is shown to result in lower pregnancy rates levels on day 2 or 3 of the cycle are associated with (kolibianakis et al., 2004). reduced pregnancy rates (kolibianakis et al., 2004). The administration of rFSH starting on day 2 or 5 in this trial, we demonstrated that raised proges- of the cycle in a GnrH antagonist co-treatment pro- terone levels can be normalised through administra- tocol for iVF/iCSi patients, yields only subtle dif- tion of a GnrH antagonist during three subsequent ferences in the endocrine profile and follicular days prior to the start of gonadotropin stimulation. development. Ovarian stimulation is initiated 3 days in case of normal progesterone at initiation of the later in the CD5 study group compared to the CD2 cycle, pretreatment with GnrH antagonists during control group, which implies a significant longer fol- three consecutive days before the onset of ovarian licular phase in the CD5 group (10.1 days in the CD2 stimulation yields a higher number of COCs per group versus 11.9 days in the CD5 group, p < 0.01). oocyte retrieval compared to a conventional GnrH The duration of the stimulation differs by 1.3 days antagonist protocol. This approach could be adopted only. This finding suggests indeed that less admin- as novel convenience tool to schedule GnrH antag- istered FSH is needed when starting with stimulation onist cycles and to aid the organisation of an ArT later during the follicular phase and a significant de- centre, through the administration of a GnrH antag- crease in total consumption of rFSH (1,364 ± 226 onist during a varying number of days (i.e. two, three (SD) iU versus 1,177 ± 295 iU; p < 0.01). More or four days), in accordance with the intended onset specifically, the need for exogenous FSH during the of ovarian stimulation. The protocol could be used first days of ovarian stimulation can be questioned, in oocyte donors to facilitate synchronisation with as the relatively high endogenous FSH concentra- the acceptor. The clinical potential of this short and tions during this period could be sufficient. Although 210 FVV inObGyn 08-blockeel_Opmaak 1 20/09/12 09:47 Pagina 211 the administration of rFSH on day 5 of the cycle can implantation rates (Filicori et al., 2005). As a corol- overrule single dominant follicle selection in the ma- lary of this, the introduction of hCG in the late fol- jority of women, more than ten per cent of the pa- licular phase could enhance uterine receptivity and tients (4 out of 39) developed mono-follicular therefore play a significant role in implantation. growth, probably due to closure of the FSH window (Fauser et al., 1993). Ovarian stimulation seems to Conclusion be feasible in the majority of patients when initiated on cycle day 5, with minimal impact on the length in this thesis, attempts to further optimise the GnrH of the follicular phase. These results suggest that by antagonist protocol in order to increase the accept- selecting the appropriate day to initiate ovarian stim- ance and the implementation of GnrH antagonists ulation (namely on cycle day 2, 3, 4 or 5) oocyte re- in general practice have been made. From a first trievals on weekends can be largely avoided and trial, we concluded that administration of a GnrH could serve as a additional planning tool to schedule antagonist normalises progesterone levels in those iVF treatment cycles at the patient’s and the centre’s cases with isolated elevated serum progesterone lev- convenience. The development of a standardised els at the start of the ArT treatment cycle, and that protocol most suitable for ovarian stimulation for all this pretreatment is compatible with adequate ovar- women seems to be elusive due to important differ- ian stimulation and results in acceptable pregnancy ences in ovarian response among patients. Patient rates. in the following trial, pretreatment with GnrH tailored regimens based on individual patient char- antagonists in case of normal progesterone yielded acteristics should be developed further. in other a trend towards a higher number of COCs compared words, mild response rather than mild stimulation to a conventional GnrH antagonist protocol. The needs further scrutiny (Fauser et al., 2010). next trial, making use of estradiol valerate as pre- treatment, showed a reduction of the proportion of Late Follicular Phase oocyte retrievals during weekend days, without af- fecting the number of COCs or ongoing pregnancy The administration of 200 iU/d of hCG can be safely rates. The fourth study shows that the administration applied in patients undergoing ArT to substitute for of rFSH starting on day 2 or day 5 of the cycle in a recombinant FSH in the final days of ovarian stim- GnrH antagonist protocol for iVF/iCSi patients ulation in an antagonist protocol. The protocol is yields a comparable endocrine profile and follicular generally applicable and the use of hCG confers a development. The fifth and sixth study dealt with dramatic reduction on the treatment cost, as com- replacing rFSH by 200iU of hCG per day in the late pared to FSH-containing preparations, like recombi- follicular phase of a GnrH antagonist protocol, nant FSH or highly purified human menopausal resulting in a decreased consumption of gonado - gonadotropins or hMG. trophins (without differences in oocyte yield and Substitution of FSH by hCG has been reported pregnancy outcome) and a similar endometrial earlier in GnrH agonist protocols (Filicori et al., histological and gene expression pattern. 2002a, 2002b, 2005). in conclusion, the purposes of the different stud- besides the clinical aspects, the impact on ies, namely increasing pregnancy chance, offering a endometrial gene expression in a standard rFSH scheduling tool for the GnrH antagonist protocol stimulation protocol, compared with a 200iU hCG and significantly reducing the treatment cost were regimen in the late follicular phase in a GnrH reached. antagonist protocol was assessed. no difference in terms of histological dating of the endometrium on References the day of oocyte retrieval could be demonstrated, and full human genome gene expression analysis Al-inany HG, Abou-Setta AM, Aboulghar M. 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