Subjects:
A total of 540 patients who underwent IVF/ICSI cycles from 2013 to 2016 and have a history of male factor infertility, tubal factor and ovulation disorders were enrolled at Lahore Institute of Fertility and Endocrinology, Hameed Latif Hospital. This retrospective study was approved by the Institutional Ethical Committee (IEC) in accordance with Helsinki Declarations.
Study design:
This was a retrospective single center, open label comparative study, with the objective to compare the efficacy of short and long acting gonadotropin releasing hormone agonist (GnRH-a) regime for controlled ovarian hyper-stimulation in subjects underwent IVF/ICSI cycles.
Inclusion criteria: Patients with age between 25-45 years, previously have not more than two IVF/ICSI cycle attempts, on day 2rd of menstrual cycle serum FSH level must be < 9 IU/L were included in this study.
Exclusion criteria: Patients with any congenital anomaly, pelvic pathology, urogenital surgery, any sexual transmitted disease, habitual abortion, alcoholic addiction, any infectious disease, underwent hormonal replacement therapy during last three months, any uterine abnormalities and immunocompromised were excluded in this study.
Estimation of Clinical Parameters:
Clinical parameters such as height and weight were recoded to compute the body mass index (BMI) according to standard protocol(8).
Valuation of endocrine dimensions:
The blood samples were collected between 8 to 10 am from cubital vein and serum were separated instantly and stored at -20C0 till the performance of hormonal assay including Follicular stimulating hormone (FSH), Luteinizing hormone (LH), estradiol (E2) and anti-mullerian duct hormone (AMH) on 2nd day of the menstrual cycle through electrochemiluminenscence Immunoassay according to the manufacturer’s instructions (Elecsys® Roche Diagnostics, Indianapolis, USA).
Therapeutic Regimen:
GnRH-agonist long acting protocol:
A total of 310 patients were recruited in the long acting protocol (LAP) group induced by a combination of GnRH-a incorporated with Follicular stimulating hormone (FSH) and Human menopausal gonadotropin (hMG). Women with regular cycle on day 21 in the mid luteal phase started with administration of intramuscular single dose of 0.1-1.2 mg long acting decapeptyl® (Triptorelin acetate; Ferring) GnRH-a injection. A complete down regulation of pituitary had done when the serum LH level < 2 IU/ml and serum E2 level < 30 pg/mL was achieved. The transvaginal ultrasound scan (TVS) revealed a less than 5mm endometrium thickness which further confirmed complete pituitary suppression. At that stage exogenous gonadotropin rFSH (5.5µg; Gonal-F™, Merk Serono) and menotropins hMG (LG™ life sciences, Korea) administration was commenced depending upon body weight, age and follicular size of the patients, on cycle day 2 at doses ranging between 75-220 IU/day and 350-450 IU/day. Accordingly, further regular dosage of rFSH and hMG was calculated on the basis of ovarian stimulation that has been monitored through transvaginal ultrasound scan (TVS) and serum E2 levels. The folliculogenesis was consecutively observed through TVS and measuring the ratio of serum E2, LH and progesterone from the 8th day to till the day of Human chorionic gonadotropin (hCG) injection (Pregnyl®, Organon), which is around 14 days post GnRH-a administration.
GnRH-agonist short protocol or Flare up regimen:
A total of 230 patients in the short acting protocol (SAP) group have got a 0.1 mg daily intramuscular dose of decapeptyl® (Triptorelin acetate; Ferring) started from day 3rd of the menstrual cycle and continued till the day of hCG. Controlled ovarian stimulation started from 2nd day of menstrual cycle at the dose of 100-220 IU of rFSH (5.5µg; Gonal-F™, Merk Serono) and 200-450 IU of hMG (LG™ life sciences, Korea) respectively. The daily dosage was adjusted in accordance with ovarian response.
Ovulation induction:
In both protocols recombinant hCG (6500-10,000 IU) was given intramuscularly to trigger the final maturation of follicles or when more than two follicles attained a diameter of 17 mm along with increased level of oestradiol 2000 pg/ml/mature follicle. While cycle cancelation has been done if there is poor ovarian response during stimulation i.e. no follicle of 15 mm will be seen on day 9, E2 level will be <5000 pg/ml on day 9, high risk of incidence of ovarian hyperstimulation syndrome (E2 level >7000-8000 pg/ml) etc. The time difference between the last gonadotropin injection and hCG regimen was no more than 24 hour. After 36 hour of hCG regimen transvaginal echo-guided ovarian puncture has been done and oocyte retrieval was performed. The assessment of oocyte quality has been performed after removing cells of the corona radiata which is based on directly under the inverted microscope. Oocyte maturity has been noted and mature oocytes of MII are microinjected. The optimal assessment of embryonic grading is based on the study of morphology such as cleavage rate, number of blastomeres, cytoplasmic appearance, extent of a-nucleated fragments, and regularity in the symmetry of blastomeres.
Pregnancy outcomes:
Fertilization was evaluated 18 to 20 hour after insemination. One or two embryos of grade I (smooth and regular blastomeres, devoid of fragmentation and embryo) or grade II (blastomeres are equal in size, minor fragmentation (< 20%) was transferred to the uterus after 3 to 5 days later using ultrasound guided catheter (Cook, Australia ). The additional embryos were frozen based on the couple consent. Biochemical pregnancy was identified by a high level of β-hCG i.e., 50 mIU/mL, which was tested 14 days post embryo transferred. A radioimmunoassay kit was used to measure the serum concentration of β-hCG. Clinical pregnancy was confirmed by means of a gestational sac and heartbeat monitored during trans-vaginal ultrasound on 6 to 7 weeks later. Miscarriage or spontaneous abortion was demarcated as termination of pregnancy before 28 weeks. Luteal phase support was given Duphaston orally (10mg) or vaginal pessaries (Utrogestan 100mg) from the day of oocyte retrieval until clinical pregnancy was ruled out.
Statistical analysis:
Statistical analysis was done using statistical package SPSS (version 21; SPSS Inch., Chicago, IL, USA). Values are presented as Means ± SD or n/N (%). The means of two groups were compared through unpaired Student’s t-test, while, categorical variables were calculated through χ2–test. Fisher’s exact test was applied to relate multiple means from different groups. Significant statistical difference was considered p<0.05.