http://informahealthcare.com/gye ISSN: 0951-3590 (print), 1473-0766 (electronic) Gynecol Endocrinol, 2014; 30(3): 209–212 ! 2014 Informa UK Ltd. DOI: 10.3109/09513590.2013.860121
PCO
A novel modified ultra-long agonist protocol improves the outcome of high body mass index women with polycystic ovary syndrome undergoing IVF/ICSI Jiongjiong Tu1,2, Ge Lin1,2,3, Changfu Lu1,2, and Fei Gong1,2 Institute of Reproductive & Stem Cell Engineering, Central South University, Changsha, Hunan Province, China, 2Reproductive & Genetic Hospital of CITIC-Xiangya, Changsha, Hunan Province, China, and 3National Engineering and Research Center for Human Stem Cells, Central South University, Changsha, Hunan Province, China Abstract
Keywords
In an attempt to evaluate the effectiveness of a novel modified ultra-long agonist (ULA) protocol on polycystic ovary syndrome (PCOS) patients undergoing in vitro fertilisation (IVF)/ intracytoplasmic sperm injection (ICSI), a retrospective study of 499 women employed with either ULA or conventional long agonist (LA) protocol was analyzed. In high BMI group (425 kg/ m2), the ULA protocol yielded significant higher clinic pregnancy rate (PR) (70.2% versus 50.8%, p50.05), implantation rate (52.7% versus 35.7%, p50.05) and live birth rate (63.8% versus 39.0%, p50.05) when compared with LA protocol. In low BMI group (25 kg/m2), the ULA protocol also demonstrated a higher clinic PR (70.8% versus 59.5%, p50.05) whereas implantation rate and live birth rate are comparable. Within ULA protocol, the clinic PR, implantation rate and live birth rate are similar between high and low BMI patients. Similarly, the clinic PR and live birth rate demonstrated no significant difference within LA group but there is a significant lower implantation rate (35.7% versus 63.9%, p50.05) observed in high BMI patients. No difference in miscarriage rate and severe OHSS rate was found among all groups. In conclusion, ULA protocol benefits the IVF outcomes of PCOS patients with high BMI status.
Body mass index, IVF/ICSI outcome, long agonist, polycystic ovary syndrome, ultra-long agonist
Introduction Polycystic ovary syndrome (PCOS) is a common endocrinopathy that affects 5–10% of women of reproductive age, which is characterized by increased ovarian androgen production, menstrual cycle irregularity and polycystic morphology on ovarian ultrasound [1]. There are two types of women with PCOS: the ‘‘lean’’ type and the ‘‘obese’’ type. A US study reported that the prevalence of obesity in women with PCOS has increased from 51% in 1987–1990 to 74% in 2000–2002, with an addition of an Italian report that 14% of women with PCOS were obese [2,3]. Compared with normal weight people, women with a raised BMI are known to have a three-fold greater risk of infertility due to disturbances in the hypothalamic–pituitary axis, menstrual cycle alterations and anovulation as well as psychological and social factors [4,5]. IVF and embryo transfer is the last option for PCOS patients coexisting with other infertility factors. The lean-type PCOS patients have been shown to have a comparable IVF outcome as non-PCOS patients [6]. However, there is still conflicting evidence regarding the effect of raised BMI on the IVF outcome. Although some studies have reported no adverse effect observed Address for correspondence: Fei Gong, MD, Institute of Reproductive & Stem Cell Engineering, Central South University, Changsha, Hunan Province 410078, China. Tel: +86 731 82355100 8401. Fax: +86 731 84497661. E-mail: [email protected]
History Received 23 May 2013 Revised 19 October 2013 Accepted 24 October 2013 Published online 19 December 2013
[7–10], other researchers demonstrated that female obesity impairs IVF outcomes including the need for higher doses of gonadotrophins, fewer oocytes collected, higher cancellation rate, reduced pregnancy and live-birth rates as well as higher miscarriage rates [11–15]. Although many controlled ovarian hyperstimulation (COH) strategies have been offered, no compelling advantage for one stimulation protocol over another has been reported for obese-type patients [16,17]. In the present study, a novel modified ultra-long agonist (ULA) protocol has been introduced to evaluate its effectiveness on the PCOS patients with different body mass indexes. These findings may help to individualize the strategies for PCOS patients undergoing IVF/ICSI.
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Materials and methods Patient population and study design This retrospective study evaluated 499 consecutive IVF cycles in women with PCOS, whose age ranged between 20 and 45 years and were in their first cycle undergoing standard IVF/ICSI at reproductive and genetic hospital of CITIC-Xiangya between the year 2010 and 2011. PCOS was defined according to the Rotterdam criteria [1]. Patients were divided into four subgroups according to the COH protocol and BMI: group I long agonist (LA) with BMI 25 kg/m2, group II ULA with BMI 25 kg/m2, group III LA with BMI 4 25 kg/m2and group IV ULA with BMI 4 25 kg/m2.
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COH protocols All patients received oral contraceptive (OC, Diane35; Bayer Scheing Pharma, Berlin, Germany) pretreatment at proceeding cycle day 3 for 21 d before stimulation. For the LA protocol, GnRH agonist, triptorelin (Decapeptyl; Ferring, Malmo, Sweden) 1.5–1.87 mg was initiated at day 18 of OC pretreatment cycle. Two days after withdrawal bleeding with discontinuation of OC, ovarian stimulation was started using 75–150 IU of recombinant human FSH (rhFSH, Gonal-F; Merck Serono SA, Geneva, Switzerland). rhFSH was administered in a step-up fashion and the dose of rhFSH was adjusted every 3–4 days according to the ovarian response. For the ULA protocol, the first desensitization was administered as the LA protocol and the second was repeated 1 month later with the same dose. Twelve days later, ovarian stimulation was commenced using urinary human menopausal gonadotropin (HMG) in a step-up fashion and the dose was adjusted every 3– 4 days according to the ovarian response. In both LA and ULA groups, recombinant hCG 5000–10 000 IU was administered subcutaneously to induce follicular maturation when most of the follicles reached a mean diameter of 18 mm. Oocyte retrieval, embryo transfer, and luteal support Oocyte retrieval was performed 34–36 h after the hCG injection by trans-vaginal ultrasound-guided double lumen needle aspiration. Ultrasound guidance was used for all embryo transfers, which were performed 3 d post-oocyte retrieval. Luteal support was provided by administering 90 mg of vaginal progesterone gel (Crinone gel 8%; Merck Serono SA, Darmstadt, Germany) once daily from the day of oocyte retrieval. Embryo transfer was cancelled for ovarian hyperstimulation syndrome (OHSS) when peak E245000 pg/mL or total retrieved oocytes 428 or in cases fulfilling one or more of the criteria for hospitalization [18]. Clinical pregnancy was defined as the presence of a gestational sac by ultrasonography, while miscarriage rate per clinical pregnancy was defined as the proportion of patients who failed to continue development before 24 weeks of gestation in all clinical pregnancies. Live birth was defined as the delivery of a fetus with signs of life after 20 completed weeks of the gestational age. Statistical analysis Statistical analysis was performed using the SPSS software package (SPSS Inc., Chicago, IL). Differences between
parameters among the groups were evaluated using t test or Mann–Whitney test, as appropriate. Differences between proportions were evaluated using the 2 or Fisher exact test. A p value of 50.05 was considered statistically significant.
Results A total of 499 IVF cycles were evaluated: 265 were in the LA-low BMI group, 122 were in the ULA- low BMI group, 62 were in the LA-high BMI group, and 50 were in the ULA-high BMI group. Baseline characteristics of the patients were analyzed and the groups did not statistically differ with respect to couple’s age, indications for IVF, endocrine profile and fertilization methods (Table 1). ULA versus LA protocols The ULA protocol was characterized by a significant lower initial LH level compared with LA protocol (0.7 0.6 versus 1.9 0.8 IU/L and 0.6 0.5 IU/L versus 1.9 0.7 IU/L, respectively, p50.05). The ULA protocol achieved higher endometrial thickness (12.9 2.8 mm versus 11.4 2.0 mm, p50.05) and more retrieved oocytes (14.9 6.4 versus 14.1 5.4, p50.05) in high BMI group while more qualified (8.8 5.8 versus 8.1 4.2 p50.01) and high quality (6.3 4.6 versus 5.2 3.6, p50.05) embryos as well as higher fertilization rate (69.3 13.0% versus 67.1 22.4%, p50.05) were obtained in low BMI group. There were no significant differences in COH duration, total used gonadotropin, progesterone and E2 level on HCG day, mature metaphase II oocyte rate, transferred embryos and so were cancellation rate (OHSS) in each BMI category (Table 2). A significant higher clinical PR (70.2% versus 50.8%, p50.05), implantation rate (52.7% versus 35.7%, p50.05) and live birth rate (63.8% versus 39.0%, p50.05) was observed in ULA-high BMI group. A similar higher clinical PR in ULA protocol (70.8% versus 59.5%, p50.05) was shown in the low BMI group while implantation rate and live birth rate were comparable. In addition, the miscarriage rate and severe OHSS rate were similar between ULA and LA groups (Table 3). Low versus high BMI group Within the ULA protocol, the high BMI group was characterized by longer COH day (12.5 2.8 versus 11.1 2.0, p50.01), more consumption of gonadotropin (2057.6 851.8 versus 1495.2 458.7, p50.01), less high-quality embryos
Table 1. Patients’ characteristics in ultra-long and long agonist groups according to different BMI subgroups. Group I, LA (BMI25) Patients Age of patients (year) Age of husbands (year) Indications for IVF (%) PCOSþtubal PCOSþmale PCOS only PCOSþtubalþmale Endocrine profile LH FSH T (total) Fertilization (%) IVF ICSI IVFþICSI
Group II, ULA (BMI25)
Group III, LA BMI425
Group IV, ULA BMI425
265 28.5 3.7 31.6 4.6
122 28.3 3.8 31.5 3.8
62 30.2 3.2 33.6 6.1
50 29.6 3.9 33.5 4.8
54.0 7.5 7.5 30.9
58.2 9.0 3.3 29.5
54.8 6.5 4.8 33.9
68.0 8.0 4.0 20.0
(143/265) (20/265) (20/265) (82/265)
8.4 5.0 6.2 1.4 0.5 0.3 72.1 (191/265) 19.2 (51/265) 8.7 (23/265)
(71/122) (11/122) (4/122) (36/122)
8.8 5.8 6.2 1.4 0.5 0.4 66.4 (81/122) 24.6 (30/122) 9.0 (11/122)
(34/62) (4/62) (3/62) (21/62)
(34/50) (4/50) (2/50) (10/50)
7.2 5.2 5.9 1.6 0.5 0.3
7.6 4.4 5.7 1.4 0.5 0.2
64.5 (40/62) 29.0 (18/62) 6.5 (4/62)
62.0 (31/50) 26.0 (13/50) 12.0 (6/50)
Ultra-long agonist protocol
DOI: 10.3109/09513590.2013.860121
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Table 2. COH characteristics after ultra-long and long agonist protocol in patients with low and high BMI.
LH on initial day Duration of COH (days) Total gonadotropin (IU) On the day of hCG injection Progesterone (ng/mL) E2 (pg/mL) Endometrial thickness (mm) No. of oocytes retrieved MII oocyte (%) Fertilization rate (%) No. of qualified embryos No. of high-quality embryos No. of embryos transferred per ET No. of cycles cancelled (%) OHSS risk Other factor
Group I, LA (BMI525)
Group II, ULA (BMI525)
Group III, LA (BMI425)
1.9 0.8 11.7 2.1 1517.6 569.2
0.7 0.6 11.1 2.0 1495.2 458.7
1.9 0.7 12.4 2.5 2116.5 662.3
0.6 0.5 12.5 2.8 2057.6 851.8
50.01*y 50.01z 50.01zô
0.5 0.4 3309.9 1458.6 11.7 2.3 15.6 6.0 81.5 15.4 67.1 22.4 8.1 4.2 5.2 3.6 2.0 0.3
0.5 0.4 3229.7 1335.2 12.3 2.4 16.0 7.5 82.0 12.3 69.3 13.0 8.8 5.8 6.3 4.6 2.0 0.3
0.6 0.3 2381.9 1022.0 11.4 2.0 13.8 5.2 79.1 14.0 67.5 19.3 7.5 3.7 5.2 3.1 2.1 0.2
0.5 0.3 2806.8 1481.1 12.9 2.8 14.8 6.3 78.9 13.7 69.8 19.6 7.1 3.4 4.6 2.9 2.0 0.3
ns 50.01ô 50.05y ns ns 50.05* 50.01*z 50.05*z ns
12.3(15/122) 0.8(1/122)1
1.6(1/62) 3.2(2/62)
4.0(1/50) 8.0(2/50)
50.05*ô /
12.8 (34/265) 1.51 (/265)4
Group IV, ULA(BMI425)
p Value
Unless otherwise indicated, values are means SD. COH, controlled ovary hyperstimulation; MII, mature metaphase II; PR, pregnancy rate. *p Value obtained by group I versus group II. yp Values obtained by group III versus group IV. zp Values obtained by group II versus group IV. ôp Values obtained by group I versus group III.
Table 3. Primary outcome after ultra-long and long agonist protocol in patients with low and high BMI.
Clinical PR per experimental therapeutics- (%) Implantation rate (%) Live birth rate per ET (%) Miscarriage rate (%) Severe OHSS (%)
Group I LA (BMI25)
Group II ULA (BMI25)
Group III LA (BMI425)
Group IV ULA (BMI425)
p Value
59.5 (135/227)
70.8 (75/106)
50.8 (30/59)
70.2 (33/47)
50.05*y
63.9 51.5 7.9 3.1
58.3 58.5 12.3 1.9
35.7 39.0 11.9 3.4
52.7 63.8 6.4 6.4
50.05*z 50.05y ns ns
(189/396) (117/227) (18/227) (7/227)
(109/187) (62/106) (13/106) (2/106)
(41/115) (23/59) (7/59) (2/59)
(49/93) (30/47) (3/47) (3/47)
*p Value obtained by group I versus group II. yp Values obtained by group III versus group IV. zp Values obtained by group I versus group III.
(7.1 3.4 versus 8.8 5.8, p50.01), and lower cancellation rate (OHSS) (4.0% versus 12.3%, p50.01). However, the primary outcomes with respect to clinical PR, implantation rate, live birth rate, miscarriage rate as well as severe OHSS rate did not reach statistical significance between low and high BMI groups. Within the LA protocol, the high BMI group also demonstrated increased consumption of gonadotropin (2116.5 662.3 versus 1517.6 569.2, p50.01), lower peak E2 (2381.9 1022.0 versus 3309.9 1458.6, p50.01), and lower cancellation rate (OHSS) (1.6% versus 12.8%, p50.01). Other parameters such as progesterone in HCG day, endometrial thickness, retrieved oocytes, mature metaphase II oocyte rate, fertilization rate and transferred embryos demonstrated no significant differences in each COH protocol. Although clinical PR, live birth rate, miscarriage rate and severe OHSS rate were comparable, the implantation rate (35.7% versus 63.9%, p50.01) was significantly decreased in LA-high BMI group.
Discussion In the present study, a novel modified ULA protocol, which is characterized by double desensitization and the use of urinary HMG, has been firstly introduced and demonstrated a significant improvement of IVF outcome in obese-type patients with PCOS
and the primary results were not impaired in contrast to those of lean type. The increased BMI in PCOS women is associated with higher androgen level, which may block dominant follicle development, cause follicular degeneration, and decrease oocyte maturation [19–21]. Although the total testosterone demonstrated no significant differences in the present study, free androgen index (FAI) might be the main negative factor influencing oocytes performance [22]. In this novel ULA protocol, double desensitization suppresses serum gonadotropins to an extreme low level, which in turn, may trigger the atresia of excessive follicles impaired by high concentration of testosterone in the follicular fluid [23,24]. Also, androgen production can be directly inhibited by decreased LH level according to the classic two-cell two-gonadotropin theory [25], which could subsequently exert protective effect on the survived oocytes before cycles. On the other hand, it should be noted that low initial LH concentrations might impair E2 synthesis [26–28]. In an attempt to resolve such a potential defect, urinary HMG that contains 75 IU LH and 75 IU FSH was employed as a compensation instead of conventional rhFSH. This modification yielded a comparable peak E2 in contrast LA protocol, indicating that ULA protocol does not affect the E2 synthesis with the replacement of urinary HMG. Moreover, the price of urinary HMG is much lower to rhFSH, which could largely reduce costs during the COH procedure.
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In our data, no consensus in the enhancement of endometrial thickness can be observed in ULA protocol. And this novel protocol also did not differently influence the progesterone in HCG day, which has been reported to negatively affect endometrium receptivity in a high level [29,30]. These findings suggested that ULA protocol might regulate the endometrium receptivity in another way, which should be further investigated. Unfortunately, ULA protocol failed to lower the miscarriage rate, which is independently associated with high BMI. It is likely that the development of miscarriage is influenced by many factors rather than obese and the novel ULA protocol could only partially correct the adverse effect. It also should be noted that low BMI rather than the COH protocol might be the main cause to develop OHSS. The high cancellation rate in lean-type patients largely contributed to the non-significant difference of severe OHSS occurrence when compared to obese-type post implantation. In summary, our study suggested that the novel modified ULA protocol yielded a better IVF outcome for PCOS patients with high BMI undergoing IVF/ICSI. For those infertile women who have problems in losing weight or financial support, ULA protocol offers a good option for better results and less costs.
Declaration of interest The authors report no declarations of interest.
References 1. Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril 2004; 81:9–25. 2. Yildiz BO, Knochenhauer ES, Azziz R. Impact of obesity on the risk for polycystic ovary syndrome. J Clin Endocrinol Metab 2008;93: 162–8. 3. Targher G, Solagna E, Tosi F, et al. Abnormal serum alanine aminotransferase levels are associated with impaired insulin sensitivity in young women with polycystic ovary syndrome. J Endocrinol Invest 2009;32:695–700. 4. Van der Steeg JW, Steures P, Eijkemans MJ, et al. Collaborative Effort for Clinical Evaluation in Reproductive Medicine Study Group. Predictive value of pregnancy history in subfertile couples: results from a nation wide cohort study in the Netherlands. Fertil Steril 2008;90:521–7. 5. Brewer C, Balen A. The adverse effects of obesity on conception and implantation. Reproduction 2010;140:347–64. 6. Ciepiela P, Baczkowski T, Brelik P, et al. Biotechnological and clinical outcome of in vitro fertilization in non-obese patients with polycystic ovarian syndrome. Folia Histochem Cytobiol 2007;45: S65–71. 7. Haghighi Z, Rezaei Z, Es-Haghi Ashtiani S. Effects of women’s body mass index on in vitro fertilization success: a retrospective cohort study. Gynecol Endocrinol 2012;28:536–9. 8. Styne-Gross A, Elkind-Hirsch K, Scott RT. Obesity does not impact implantation rates or pregnancy outcome in women attempting conception through oocyte donation. Fertil Steril 2005;83:1629–34. 9. Dechaud H, Anahory T, Reyftmann L, et al. Obesity does not adversely affect results in patients who are undergoing in vitro fertilization and embryo transfer. Eur J Obstet Gynecol Reprod Biol 2006;127:88–93.
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10. Matalliotakis I, Cakmak H, Sakkas D, et al. Impact of body mass index on IVF and ICSI outcome: a retrospective study. Reprod Biomed Online 2008;16:778–83. 11. Wang JX, Davies M, Norman RJ. Body mass and probability of pregnancy during assisted reproduction treatment: retrospective study. BMJ 2000;321:1320–1. 12. Fedorcsak P, Storeng R, Dale PO, et al. Obesity is a risk factor for early pregnancy loss after IVF or ICSI. Acta Obstet Gynecol Scand 2000;79:43–8. 13. Fedorcsak P, Dale PO, Storeng R, et al. Impact of overweight and underweight on assisted reproduction treatment. Hum Reprod 2004; 19:2523–8. 14. Veleva Z, Tiitinen A, Vilska S, et al. High and low BMI increase the risk of miscarriage after IVF/ICSI and FET. Hum Reprod 2008;23:878–84. 15. Robker RL. Evidence that obesity alters the quality of oocytes and embryos. Pathophysiology 2008;15:115–21. 16. Orvieto R, Meltcer S, Homburg R, et al. What is the preferred GnRH analogue for polycystic ovary syndrome patients undergoing controlled ovarian hyperstimulation for in vitro fertilization? Fertil Steril 2009;91:1466–8. 17. Marci R, Lisi F, Soave I, et al. Ovarian stimulation in women with high and normal body mass index: GnRH agonist versus GnRH antagonist. Gynecol Endocrinol 2012;10:792–5. 18. Navot D, Bergh PA, Laufer N. Ovarian hyperstimulation syndrome in novel reproductive technologies: prevention and treatment. Fertil Steril 1992;58:249–61. 19. Billig H, Furuta I, Hsueh AJW. Estrogen inhibits and androgen enhances ovarian granulosa cell apoptosis. Endocrinology 1993;133: 2204–12. 20. Tesarik J, Mendoza C. Nongenomic effects of 17 beta-estradiol on maturing human oocytes: relationship to oocyte developmental potential. J Clin Endocrinol Metab 1995;80:1438–43. 21. Kurzawa R, Ciepiela P, Baczkowski T, et al. Comparison of embryological and clinical outcome in GnRH antagonist vs. GnRH agonist protocols for in vitro fertilization in PCOS non-obese patients. A prospective randomized study. J Assist Reprod Genet 2008;25:365–74. 22. Lim SS, Norman RJ, Davies MJ, Moran LJ. The effect of obesity on polycystic ovary syndrome: a systematic review and meta-analysis. Obes Rev 2013;14:95–109. 23. Chun SY, Billig H, Tilly JL, et al. Gonadotropin suppression of apoptosis in cultured preovulatory follicles: mediatory role of endogenous IGF-I. Endocrinology 1994;135:1845–53. 24. Walters KA, Allan CM, Handelsman DJ. Androgen actions and the ovary. Biol Reprod 2008;78:380–9. 25. Falck S. Site of the production of estrogen in rat ovary as studies in micro-transplants [PhD thesis]. Sweden: University of Lund; 1959. 26. Flemming R, Iloyd F, Herbert M, et al. Effects of profound suppression of luteinizing hormone during ovarian stimulation on follilicular activity, oocyte and embryo function in cycles stimulation with purified follicle stimulation hormone. Hum Reprod 1998; 13:1788–92. 27. Flemming R, Rehka P, Deshpande N, et al. Suppression of LH during ovarian stimulation: effects differ in cycles stimulated with purified urinary purified urinary FSH and recombinant FSH. Hum Reprod 2000;15:1440–5. 28. Shoham Z. The clinical therapeutic window for luteinizing hormone in controlled ovarian stimulation. Fertil Steril 2002;77:1170–7. 29. Al-Azemi M, Kyrou D, Kolibianakis EM, et al. Elevated progesterone during ovarian stimulation for IVF. Reprod Biomed Online 2012;24:381–8. 30. Huang CC, Lien YR, Chen HF, et al. The duration of pre-ovulatory serum progesterone elevation before hCG administration affects the outcome of IVF/ICSI cycles. Hum Reprod 2012;27:2036–45.
PCO
A novel modified ultra-long agonist protocol improves the outcome of high body mass index women with polycystic ovary syndrome undergoing IVF/ICSI Jiongjiong Tu1,2, Ge Lin1,2,3, Changfu Lu1,2, and Fei Gong1,2 Institute of Reproductive & Stem Cell Engineering, Central South University, Changsha, Hunan Province, China, 2Reproductive & Genetic Hospital of CITIC-Xiangya, Changsha, Hunan Province, China, and 3National Engineering and Research Center for Human Stem Cells, Central South University, Changsha, Hunan Province, China Abstract
Keywords
In an attempt to evaluate the effectiveness of a novel modified ultra-long agonist (ULA) protocol on polycystic ovary syndrome (PCOS) patients undergoing in vitro fertilisation (IVF)/ intracytoplasmic sperm injection (ICSI), a retrospective study of 499 women employed with either ULA or conventional long agonist (LA) protocol was analyzed. In high BMI group (425 kg/ m2), the ULA protocol yielded significant higher clinic pregnancy rate (PR) (70.2% versus 50.8%, p50.05), implantation rate (52.7% versus 35.7%, p50.05) and live birth rate (63.8% versus 39.0%, p50.05) when compared with LA protocol. In low BMI group (25 kg/m2), the ULA protocol also demonstrated a higher clinic PR (70.8% versus 59.5%, p50.05) whereas implantation rate and live birth rate are comparable. Within ULA protocol, the clinic PR, implantation rate and live birth rate are similar between high and low BMI patients. Similarly, the clinic PR and live birth rate demonstrated no significant difference within LA group but there is a significant lower implantation rate (35.7% versus 63.9%, p50.05) observed in high BMI patients. No difference in miscarriage rate and severe OHSS rate was found among all groups. In conclusion, ULA protocol benefits the IVF outcomes of PCOS patients with high BMI status.
Body mass index, IVF/ICSI outcome, long agonist, polycystic ovary syndrome, ultra-long agonist
Introduction Polycystic ovary syndrome (PCOS) is a common endocrinopathy that affects 5–10% of women of reproductive age, which is characterized by increased ovarian androgen production, menstrual cycle irregularity and polycystic morphology on ovarian ultrasound [1]. There are two types of women with PCOS: the ‘‘lean’’ type and the ‘‘obese’’ type. A US study reported that the prevalence of obesity in women with PCOS has increased from 51% in 1987–1990 to 74% in 2000–2002, with an addition of an Italian report that 14% of women with PCOS were obese [2,3]. Compared with normal weight people, women with a raised BMI are known to have a three-fold greater risk of infertility due to disturbances in the hypothalamic–pituitary axis, menstrual cycle alterations and anovulation as well as psychological and social factors [4,5]. IVF and embryo transfer is the last option for PCOS patients coexisting with other infertility factors. The lean-type PCOS patients have been shown to have a comparable IVF outcome as non-PCOS patients [6]. However, there is still conflicting evidence regarding the effect of raised BMI on the IVF outcome. Although some studies have reported no adverse effect observed Address for correspondence: Fei Gong, MD, Institute of Reproductive & Stem Cell Engineering, Central South University, Changsha, Hunan Province 410078, China. Tel: +86 731 82355100 8401. Fax: +86 731 84497661. E-mail: [email protected]
History Received 23 May 2013 Revised 19 October 2013 Accepted 24 October 2013 Published online 19 December 2013
[7–10], other researchers demonstrated that female obesity impairs IVF outcomes including the need for higher doses of gonadotrophins, fewer oocytes collected, higher cancellation rate, reduced pregnancy and live-birth rates as well as higher miscarriage rates [11–15]. Although many controlled ovarian hyperstimulation (COH) strategies have been offered, no compelling advantage for one stimulation protocol over another has been reported for obese-type patients [16,17]. In the present study, a novel modified ultra-long agonist (ULA) protocol has been introduced to evaluate its effectiveness on the PCOS patients with different body mass indexes. These findings may help to individualize the strategies for PCOS patients undergoing IVF/ICSI.
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1
Materials and methods Patient population and study design This retrospective study evaluated 499 consecutive IVF cycles in women with PCOS, whose age ranged between 20 and 45 years and were in their first cycle undergoing standard IVF/ICSI at reproductive and genetic hospital of CITIC-Xiangya between the year 2010 and 2011. PCOS was defined according to the Rotterdam criteria [1]. Patients were divided into four subgroups according to the COH protocol and BMI: group I long agonist (LA) with BMI 25 kg/m2, group II ULA with BMI 25 kg/m2, group III LA with BMI 4 25 kg/m2and group IV ULA with BMI 4 25 kg/m2.
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COH protocols All patients received oral contraceptive (OC, Diane35; Bayer Scheing Pharma, Berlin, Germany) pretreatment at proceeding cycle day 3 for 21 d before stimulation. For the LA protocol, GnRH agonist, triptorelin (Decapeptyl; Ferring, Malmo, Sweden) 1.5–1.87 mg was initiated at day 18 of OC pretreatment cycle. Two days after withdrawal bleeding with discontinuation of OC, ovarian stimulation was started using 75–150 IU of recombinant human FSH (rhFSH, Gonal-F; Merck Serono SA, Geneva, Switzerland). rhFSH was administered in a step-up fashion and the dose of rhFSH was adjusted every 3–4 days according to the ovarian response. For the ULA protocol, the first desensitization was administered as the LA protocol and the second was repeated 1 month later with the same dose. Twelve days later, ovarian stimulation was commenced using urinary human menopausal gonadotropin (HMG) in a step-up fashion and the dose was adjusted every 3– 4 days according to the ovarian response. In both LA and ULA groups, recombinant hCG 5000–10 000 IU was administered subcutaneously to induce follicular maturation when most of the follicles reached a mean diameter of 18 mm. Oocyte retrieval, embryo transfer, and luteal support Oocyte retrieval was performed 34–36 h after the hCG injection by trans-vaginal ultrasound-guided double lumen needle aspiration. Ultrasound guidance was used for all embryo transfers, which were performed 3 d post-oocyte retrieval. Luteal support was provided by administering 90 mg of vaginal progesterone gel (Crinone gel 8%; Merck Serono SA, Darmstadt, Germany) once daily from the day of oocyte retrieval. Embryo transfer was cancelled for ovarian hyperstimulation syndrome (OHSS) when peak E245000 pg/mL or total retrieved oocytes 428 or in cases fulfilling one or more of the criteria for hospitalization [18]. Clinical pregnancy was defined as the presence of a gestational sac by ultrasonography, while miscarriage rate per clinical pregnancy was defined as the proportion of patients who failed to continue development before 24 weeks of gestation in all clinical pregnancies. Live birth was defined as the delivery of a fetus with signs of life after 20 completed weeks of the gestational age. Statistical analysis Statistical analysis was performed using the SPSS software package (SPSS Inc., Chicago, IL). Differences between
parameters among the groups were evaluated using t test or Mann–Whitney test, as appropriate. Differences between proportions were evaluated using the 2 or Fisher exact test. A p value of 50.05 was considered statistically significant.
Results A total of 499 IVF cycles were evaluated: 265 were in the LA-low BMI group, 122 were in the ULA- low BMI group, 62 were in the LA-high BMI group, and 50 were in the ULA-high BMI group. Baseline characteristics of the patients were analyzed and the groups did not statistically differ with respect to couple’s age, indications for IVF, endocrine profile and fertilization methods (Table 1). ULA versus LA protocols The ULA protocol was characterized by a significant lower initial LH level compared with LA protocol (0.7 0.6 versus 1.9 0.8 IU/L and 0.6 0.5 IU/L versus 1.9 0.7 IU/L, respectively, p50.05). The ULA protocol achieved higher endometrial thickness (12.9 2.8 mm versus 11.4 2.0 mm, p50.05) and more retrieved oocytes (14.9 6.4 versus 14.1 5.4, p50.05) in high BMI group while more qualified (8.8 5.8 versus 8.1 4.2 p50.01) and high quality (6.3 4.6 versus 5.2 3.6, p50.05) embryos as well as higher fertilization rate (69.3 13.0% versus 67.1 22.4%, p50.05) were obtained in low BMI group. There were no significant differences in COH duration, total used gonadotropin, progesterone and E2 level on HCG day, mature metaphase II oocyte rate, transferred embryos and so were cancellation rate (OHSS) in each BMI category (Table 2). A significant higher clinical PR (70.2% versus 50.8%, p50.05), implantation rate (52.7% versus 35.7%, p50.05) and live birth rate (63.8% versus 39.0%, p50.05) was observed in ULA-high BMI group. A similar higher clinical PR in ULA protocol (70.8% versus 59.5%, p50.05) was shown in the low BMI group while implantation rate and live birth rate were comparable. In addition, the miscarriage rate and severe OHSS rate were similar between ULA and LA groups (Table 3). Low versus high BMI group Within the ULA protocol, the high BMI group was characterized by longer COH day (12.5 2.8 versus 11.1 2.0, p50.01), more consumption of gonadotropin (2057.6 851.8 versus 1495.2 458.7, p50.01), less high-quality embryos
Table 1. Patients’ characteristics in ultra-long and long agonist groups according to different BMI subgroups. Group I, LA (BMI25) Patients Age of patients (year) Age of husbands (year) Indications for IVF (%) PCOSþtubal PCOSþmale PCOS only PCOSþtubalþmale Endocrine profile LH FSH T (total) Fertilization (%) IVF ICSI IVFþICSI
Group II, ULA (BMI25)
Group III, LA BMI425
Group IV, ULA BMI425
265 28.5 3.7 31.6 4.6
122 28.3 3.8 31.5 3.8
62 30.2 3.2 33.6 6.1
50 29.6 3.9 33.5 4.8
54.0 7.5 7.5 30.9
58.2 9.0 3.3 29.5
54.8 6.5 4.8 33.9
68.0 8.0 4.0 20.0
(143/265) (20/265) (20/265) (82/265)
8.4 5.0 6.2 1.4 0.5 0.3 72.1 (191/265) 19.2 (51/265) 8.7 (23/265)
(71/122) (11/122) (4/122) (36/122)
8.8 5.8 6.2 1.4 0.5 0.4 66.4 (81/122) 24.6 (30/122) 9.0 (11/122)
(34/62) (4/62) (3/62) (21/62)
(34/50) (4/50) (2/50) (10/50)
7.2 5.2 5.9 1.6 0.5 0.3
7.6 4.4 5.7 1.4 0.5 0.2
64.5 (40/62) 29.0 (18/62) 6.5 (4/62)
62.0 (31/50) 26.0 (13/50) 12.0 (6/50)
Ultra-long agonist protocol
DOI: 10.3109/09513590.2013.860121
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Table 2. COH characteristics after ultra-long and long agonist protocol in patients with low and high BMI.
LH on initial day Duration of COH (days) Total gonadotropin (IU) On the day of hCG injection Progesterone (ng/mL) E2 (pg/mL) Endometrial thickness (mm) No. of oocytes retrieved MII oocyte (%) Fertilization rate (%) No. of qualified embryos No. of high-quality embryos No. of embryos transferred per ET No. of cycles cancelled (%) OHSS risk Other factor
Group I, LA (BMI525)
Group II, ULA (BMI525)
Group III, LA (BMI425)
1.9 0.8 11.7 2.1 1517.6 569.2
0.7 0.6 11.1 2.0 1495.2 458.7
1.9 0.7 12.4 2.5 2116.5 662.3
0.6 0.5 12.5 2.8 2057.6 851.8
50.01*y 50.01z 50.01zô
0.5 0.4 3309.9 1458.6 11.7 2.3 15.6 6.0 81.5 15.4 67.1 22.4 8.1 4.2 5.2 3.6 2.0 0.3
0.5 0.4 3229.7 1335.2 12.3 2.4 16.0 7.5 82.0 12.3 69.3 13.0 8.8 5.8 6.3 4.6 2.0 0.3
0.6 0.3 2381.9 1022.0 11.4 2.0 13.8 5.2 79.1 14.0 67.5 19.3 7.5 3.7 5.2 3.1 2.1 0.2
0.5 0.3 2806.8 1481.1 12.9 2.8 14.8 6.3 78.9 13.7 69.8 19.6 7.1 3.4 4.6 2.9 2.0 0.3
ns 50.01ô 50.05y ns ns 50.05* 50.01*z 50.05*z ns
12.3(15/122) 0.8(1/122)1
1.6(1/62) 3.2(2/62)
4.0(1/50) 8.0(2/50)
50.05*ô /
12.8 (34/265) 1.51 (/265)4
Group IV, ULA(BMI425)
p Value
Unless otherwise indicated, values are means SD. COH, controlled ovary hyperstimulation; MII, mature metaphase II; PR, pregnancy rate. *p Value obtained by group I versus group II. yp Values obtained by group III versus group IV. zp Values obtained by group II versus group IV. ôp Values obtained by group I versus group III.
Table 3. Primary outcome after ultra-long and long agonist protocol in patients with low and high BMI.
Clinical PR per experimental therapeutics- (%) Implantation rate (%) Live birth rate per ET (%) Miscarriage rate (%) Severe OHSS (%)
Group I LA (BMI25)
Group II ULA (BMI25)
Group III LA (BMI425)
Group IV ULA (BMI425)
p Value
59.5 (135/227)
70.8 (75/106)
50.8 (30/59)
70.2 (33/47)
50.05*y
63.9 51.5 7.9 3.1
58.3 58.5 12.3 1.9
35.7 39.0 11.9 3.4
52.7 63.8 6.4 6.4
50.05*z 50.05y ns ns
(189/396) (117/227) (18/227) (7/227)
(109/187) (62/106) (13/106) (2/106)
(41/115) (23/59) (7/59) (2/59)
(49/93) (30/47) (3/47) (3/47)
*p Value obtained by group I versus group II. yp Values obtained by group III versus group IV. zp Values obtained by group I versus group III.
(7.1 3.4 versus 8.8 5.8, p50.01), and lower cancellation rate (OHSS) (4.0% versus 12.3%, p50.01). However, the primary outcomes with respect to clinical PR, implantation rate, live birth rate, miscarriage rate as well as severe OHSS rate did not reach statistical significance between low and high BMI groups. Within the LA protocol, the high BMI group also demonstrated increased consumption of gonadotropin (2116.5 662.3 versus 1517.6 569.2, p50.01), lower peak E2 (2381.9 1022.0 versus 3309.9 1458.6, p50.01), and lower cancellation rate (OHSS) (1.6% versus 12.8%, p50.01). Other parameters such as progesterone in HCG day, endometrial thickness, retrieved oocytes, mature metaphase II oocyte rate, fertilization rate and transferred embryos demonstrated no significant differences in each COH protocol. Although clinical PR, live birth rate, miscarriage rate and severe OHSS rate were comparable, the implantation rate (35.7% versus 63.9%, p50.01) was significantly decreased in LA-high BMI group.
Discussion In the present study, a novel modified ULA protocol, which is characterized by double desensitization and the use of urinary HMG, has been firstly introduced and demonstrated a significant improvement of IVF outcome in obese-type patients with PCOS
and the primary results were not impaired in contrast to those of lean type. The increased BMI in PCOS women is associated with higher androgen level, which may block dominant follicle development, cause follicular degeneration, and decrease oocyte maturation [19–21]. Although the total testosterone demonstrated no significant differences in the present study, free androgen index (FAI) might be the main negative factor influencing oocytes performance [22]. In this novel ULA protocol, double desensitization suppresses serum gonadotropins to an extreme low level, which in turn, may trigger the atresia of excessive follicles impaired by high concentration of testosterone in the follicular fluid [23,24]. Also, androgen production can be directly inhibited by decreased LH level according to the classic two-cell two-gonadotropin theory [25], which could subsequently exert protective effect on the survived oocytes before cycles. On the other hand, it should be noted that low initial LH concentrations might impair E2 synthesis [26–28]. In an attempt to resolve such a potential defect, urinary HMG that contains 75 IU LH and 75 IU FSH was employed as a compensation instead of conventional rhFSH. This modification yielded a comparable peak E2 in contrast LA protocol, indicating that ULA protocol does not affect the E2 synthesis with the replacement of urinary HMG. Moreover, the price of urinary HMG is much lower to rhFSH, which could largely reduce costs during the COH procedure.
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In our data, no consensus in the enhancement of endometrial thickness can be observed in ULA protocol. And this novel protocol also did not differently influence the progesterone in HCG day, which has been reported to negatively affect endometrium receptivity in a high level [29,30]. These findings suggested that ULA protocol might regulate the endometrium receptivity in another way, which should be further investigated. Unfortunately, ULA protocol failed to lower the miscarriage rate, which is independently associated with high BMI. It is likely that the development of miscarriage is influenced by many factors rather than obese and the novel ULA protocol could only partially correct the adverse effect. It also should be noted that low BMI rather than the COH protocol might be the main cause to develop OHSS. The high cancellation rate in lean-type patients largely contributed to the non-significant difference of severe OHSS occurrence when compared to obese-type post implantation. In summary, our study suggested that the novel modified ULA protocol yielded a better IVF outcome for PCOS patients with high BMI undergoing IVF/ICSI. For those infertile women who have problems in losing weight or financial support, ULA protocol offers a good option for better results and less costs.
Declaration of interest The authors report no declarations of interest.
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