1 Clínica de Medicina de la Reproducción y Ginecología FIVMadrid, Madrid and 2 Unidad de Reproducción, Hospital Severo Ochoa, Madrid, Spain
3 To whom correspondence should be addressed at: Clínica de Medicina de la Reproducción y Ginecología FIV Madrid, C/Álvarez de Baena 4 bajo, 28006 Madrid, Spain. Email: ehernandezm{at}fivmadrid.es
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Abstract |
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Key words: GnRH antagonist/intrauterine insemination/pregnancy rates
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Introduction |
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The inclusion of the GnRH antagonist in assisted reproduction techniques allows ovulation to be postponed since the antagonist will suppress gonadotrophin release, block the possibility of premature LH surges, and, consequently, premature luteinization of the follicles (Frydman et al., 1991; Diedrich et al., 1994
; European and Middle East Orgalutran Study Group, 2001
; Fluker et al., 2001
). Furthermore, this control of untimely LH release has been extensively confirmed and demonstrated to successfully protect follicular development against unexpected luteinization in IVF (Diedrich et al., 1994
; European and Middle East Orgalutran Study Group, 2001
; Fluker et al., 2001
; Ricciarelli et al., 2003
; Acevedo-Martin et al., 2004
).
With this in mind, we thought that if pregnancy rates in IUI were related to the number of mature follicles present on the day hCG was indicated (Nuojua-Huttunen et al., 1999; Dickey et al., 2002
; Duran et al., 2002
; Houmard et al., 2002
; Kaplan et al., 2002
), and if the limiting factor for follicular development was premature luteinization, why not control unexpected LH surges during the COSIUI cycles with an antagonist of the GnRH? This would: (i) maintain steady growth up to >20 mm in diameter among the recruited follicles; (ii) allow us to time ovulation in a synchronized manner with more than one mature follicle and, hopefully, increase pregnancy rates.
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Materials and methods |
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The GnRH antagonist is already routinely used for IVF in our centres, and the patients were recruited following the guidelines set by the Spanish Committee of Assisted Reproductive Techniques, in accordance with the Helsinki Declaration of 1975 on human research.
Inclusion criteria
The main inclusion criteria in women were age between 18 and 38 years, regular menstrual cycle, primary or secondary infertility lasting for 12 months, body mass index between 19 and 25 kg/m2, normal prolactin levels, normal thyroid function, normal uterine cavity and bilateral tubal patency assessed by hysterosalpingography and/or laparoscopy.
Women with hormone values outside the reference range by day 34 of their menstrual period (FSH levels >10 mIU/l) and with polycystic ovarian syndrome were excluded from this study.
Semen analysis was performed at least twice and IUI was carried out if the total motile spermatozoid swim-up count was >10 x 106/ml.
Hormonal treatment
COS was performed in both groups with recombinant FSH (rFSH, Puregon; Organon Inc., Spain). Patients included in this study underwent an ultrasound scan between the third and fourth day of their menstrual cycle and were subsequently randomized by a computer-generated random listing into two groups. The study was performed in two centres. Patients were randomly assigned by a computer-generated list in the order of their enrolment.
GnRH antagonist group
Forty patients (30 patients from the first centre and 10 from the second centre) were subjected to a COS protocol in which the LH surge was suppressed with the GnRH antagonist ganirelix acetate (Orgalutran; Organon Inc., Spain), as follows. On the third or fourth day of their menstrual period, the patients were examined by ultrasound to ensure ovarian quiescence. A fixed dose of 100 IU/per day of rFSH was then given to induce follicle recruitment for 5 days. At day 6 of ovarian stimulation, an ultrasound was performed to adjust FSH dose, if necessary. When the recruited follicles were 16 mm or E2 levels were >300 pg/ml, 0.25 mg of ganirelix was subcutaneously injected daily following the manufacturer's guidelines until the day hCG was given. Subsequently, follicular development was controlled by sequential ultrasound scans every 2 days. When adequate ovarian response was observed (follicles =20 mm), 5000 IU/i.m. hCG (hCG-Lepori; Farma-Lepori, Spain) was administered. IUI was cancelled if more than four follicles (>1620 mm) were present, in order to reduce the risk of multiple pregnancy. No severe ovarian hyperstimulation syndrome occurred. One cycle was converted to an IVF cycle due to excessive ovarian response (eight follicles
16 mm).
Control group
Forty-two patients (31 from the first centre and 11 from the second centre) were subjected to the same COS protocol previously described except that the GnRH antagonist (Ganirelix) was not used and hCG (5000 IU) was administered once the leading follicle reached the 1820 mm boundary, on ultrasound examination. As in the other group, IUI was cancelled if more than four follicles (>1620 mm) were present. One cycle was cancelled in order to avoid a multiple pregnancy since ultrasound had revealed seven follicles 16 mm.
Semen preparation
Semen specimens were obtained by masturbation into a sterile jar after 23 days of abstinence and a few hours before the scheduled insemination. After liquefaction for 2030 min, the specimen was mixed and diluted with 2 ml of Ham's F-10 medium (Gibco, UK) The mixture was centrifuged at 600g for 510 min, and the supernatant discarded; 0.3 ml of IVF Universal medium (Medicult, Denmark) was added and the mixture incubated for 3045 min at room temperature. After the swim-up, the most active motile sperm were isolated by aspiration and used for insemination.
IUI procedure and luteal phase support
A single insemination was performed, 3638 h post-hCG, in both groups using a Lee catheter (Vygon, France) inserted through the cervix. A limited insemination volume (0.3 ml) was delivered into the uterine cavity and bed rest was maintained for 10 min after IUI.
The luteal phase was routinely supplemented (in all patients in both groups) with 300 mg/day/vaginally of natural micronized progesterone (Utrogestan; Seid, Spain) starting after the IUI procedure on the same day.
Sixteen days after the insemination, an hCG assay (HCG; BioMerieux, France) was performed. If the assay was positive, transvaginal ultrasonography was scheduled for 2 weeks later. The concurrency of a positive hCG and embryo(s) with a positive heart beat (seen by ultrasound) was defined as a clinical pregnancyotherwise the positive hCG test was considered to be a biochemical pregnancy. Progesterone was maintained until the 12th week of pregnancy if a clinical pregnancy was evident.
Hormonal determination
FSH, LH, E2 and hCG serum levels were determined with a commercial enzyme immunoassay kit (Vidas; Biomérieux, Spain). Blood samples were collected on the third or fourth day of the cycle (E2, LH and FSH) and before given hCG (E2).
Statistical analysis
Data were expressed as the mean ± SD. Continuous variables were compared with Student's t-test. The 2-test and Fisher test were used to compare clinical outcome between the two groups. The analysis was carried out using the statistical package for social sciences (SPSS Inc., USA). P<0.05 was considered significant.
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Results |
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As seen in Table I, no significant differences in basal serum levels (third and fourth days of their menstrual cycle) for FSH (5.5±2.1 versus 6.1±1.7), LH (4.7±4.2 versus 6.1±4.8) or E2 (38.2±15.4 versus 38.3±12.7) were noted between the GnRH antagonist-treated group and the control group.
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Pregnancy rates were significantly increased in the group of patients receiving the GnRH antagonist (38%) compared to the control group (14%). To date, except for one biochemical pregnancy in the control group, all the other pregnancies are ongoing. Furthermore, 93% of the pregnancies in the GnRH antagonist group (14/15) and 100% of the pregnancies in the control group (6/6) were single gestations. The only non-single pregnancy (triplets) occurred in the antagonist group.
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Discussion |
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The rationale for this hypothesis was based on the capacity of the GnRH antagonist to rapidly inhibit LH release by the gonadotrophs and thereby control and avoid premature luteinization in IVF (Frydman et al., 1991; Diedrich et al., 1994
; Reissmann et al., 1995
; Olivennes et al., 2002
). We thought that the same mechanism could be used in COSIUI advantageously to avoid premature luteinization of the leading follicle(s) and to expand follicular development so that ovulation could be induced once follicle size was between 19 and 20 mm. Furthermore, since COS generally develops a cohort of follicles, avoiding premature luteinization with ganirelix acetate would increase the number of ovulatory follicles available for the IUI procedure and, hopefully, increase pregnancy rates (Nuojua-Huttunen et al, 1999
; Dickey et al., 2002
; Duran et al., 2002
; Houmard et al., 2002
; Kaplan et al., 2002
).
Our results support this hypothesis since the inclusion of the GnRH antagonist (1.8±0.7 ampoules) in the COSIUI protocol significantly (P<0.05) increased the number of mature follicles (16 mm) in the GnRH antagonist group with respect to the control group (2.4±1.4 versus 1.7±1.2 respectively). The total amount of FSH used by patients receiving GnRH antagonist (707±240 total IU) was slightly greater than in the controls (657±194 total units), but this difference was not significant (Table II).
Nevertheless, we were concerned by the increased cost of including the GnRH antagonist in the IUI protocols. We calculated that including this treatment would increase the cost of each cycle by a minimum of 100 and a maximum of
150. In return by using a GnRH antagonist that will significantly reduce the risk of cycle cancellation and the associated emotional stress to the patients.
We were aware of the risk that increasing the number of mature follicles could also increase multiple pregnancy rates (Dickey et al., 2001; Khalil et al., 2001
; Tur et al., 2001
), and, in fact, the only multiple gestation in this study was in the group treated with GnRH antagonist (Table III). For this reason, IUI was cancelled whenever a patient had more than four 1620 mm follicles, regardless of how many follicles were <15 mm (Claman, 2004
; Osuna et al., 2004
). Several publications have indicated that the risk of multiple pregnancies rises with the number of 15 mm follicles (Tur et al., 2001
; Dickey et al., 2001
; Khalil et al., 2001
; Ghosh et al., 2003
) and some of the follicles we classified as 15 mm could actually have measured 16 mm (given the difficulties of distinguishing between a 16 or 15 mm follicle by ultrasound). However, our clinic's historical average for multiple gestations using the criterion of ignoring the number of <15 mm follicles when deciding IUI is 20% (only twins, no triplets), so we followed the same rationale in this study and only one couple in the GnRH antagonist group had a multiple pregnancy.
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Although Kolibianakis et al. (2003) report that patients receiving the GnRH antagonist during IVF cycles seem to present a dysfunctional endometrium, Ragni et al. (2001)
have demonstrated that the luteal phase profile (progesterone concentration) in COSIUI/GnRH antagonist cycles seems to be unaffected in IUI cycles treated with recombinant FSH in combination with GnRH antagonist. Nevertheless, to avoid a hypothetical effect of the antagonist on the function of the corpus luteum, we routinely supplemented the luteal phase with natural micronized progesterone in all the IUI procedures.
In conclusion, the addition of the GnRH antagonist to COSIUI cycles significantly increased pregnancy rates in our patients. Since this increase seems to be related to the number of follicles recruited, clinicians should balance this benefit against the risk of multiple gestation in IUI.
Finally, because only a relatively small number of patients has been analysed, the results of this study are only preliminary. However, in our opinion some immediate emotional and clinical benefits (lower cancellation rates, avoidance of premature luteinization) can be obtained using the GnRH antagonist in the COSIUI cycles.
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References |
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Claman P (2004) Simplifying superovulation and intrauterine insemination treatment: evidence and clinical decision making. Fertil Steril 82, 3233.[CrossRef][ISI]
Dickey RP, Taylor SN, Lu PY, Sartor BM, Rye PH and Pyrzak R (2001) Relationship of follicle numbers and estradiol levels to multiple implantation in 3,608 intrauterine insemination cycles. Fertil Steril 75, 6978.[CrossRef][ISI][Medline]
Dickey RP, Taylor SN, Lu PY, Sartor BM, Rye PH and Pyrzak R (2002) Effect of diagnosis, age, sperm quality, and number of preovulatory follicles on the outcome of multiple cycles of clomiphene citrate-intrauterine insemination. Fertil Steril 78, 10881095.[CrossRef][ISI][Medline]
Diedrich K, Diedrich C, Santos E, Zoll C, al-Hasani S, Reissmann T, Krebs D and Klingmuller D (1994) Suppression of the endogenous luteinizing hormone surge by the gonadotrophin-releasing hormone antagonist Cetrorelix during ovarian stimulation. Hum Reprod 9, 788791.[Abstract]
Duran HE, Morshedi M, Kruger T and Oehninger S (2002) Intrauterine insemination: a systematic review on determinants of success. Hum Reprod Update 8, 373384.
European and Middle East Orgalutran Study Group (2001) Comparable clinical outcome using the GnRH antagonist ganirelix or a long protocol of the GnRH agonist triptorelin for the prevention of premature LH surges in women undergoing ovarian stimulation. Hum Reprod 16, 644651.
Fluker M, Grifo J, Leader A, Levy M, Meldrum D, Muasher SJ, Rinehart J, Rosenwaks Z, Scott RT, Jr, Schoolcraft W and Shapiro DB (2001) North American Ganirelix Study Group Efficacy and safety of ganirelix acetate versus leuprolide acetate in women undergoing controlled ovarian hyperstimulation. Fertil Steril 75, 3845.[CrossRef][ISI][Medline]
Frydman R, Cornel C, de Ziegler D, Taieb J, Spitz IM and Bouchard P (1991) Prevention of premature luteinizing hormone and progesterone rise with a gonadotropin-releasing hormone antagonist, Nal-Glu, in controlled ovarian hyperstimulation. Fertil Steril 56, 923927.[ISI][Medline]
Ghosh C, Buck G, Priore R, Wacktawski-Wende J and Severino M (2003) Follicular response and pregnancy among infertile women undergoing ovulation induction and intrauterine insemination. Fertil Steril 80, 328335.[CrossRef][ISI][Medline]
Hernández ER (2000) Embryo implantation and GnRH antagonists: embryo implantation, the Rubicon for GnRH antagonists. Hum Reprod 15, 12111216.
Houmard BS, Juang MP, Soules MR and Fujimoto VY (2002) Factors influencing pregnancy rates with a combined clomiphene citrate/gonadotropin protocol for non-assisted reproductive technology fertility treatment. Fertil Steril 77, 384386.[CrossRef][ISI][Medline]
Kaplan PF, Katz SL, Thompson AK and Freund RD (2002) Cycle fecundity in controlled ovarian hyperstimulation and intrauterine insemination. Influence of the number of mature follicles at hCG administration. J Reprod Med 47, 3539.
Khalil MR, Rasmussen PE, Erb K, Laursen SB, Rex S and Westergaard LG (2001) Homologous intrauterine insemination. An evaluation of prognostic factors based on a review of 2473 cycles.Acta Obstet Gynecol Scand 80, 7481.
Kolibianakis EM, Bourgain C, Platteau P, Albano C, Van Steirteghem AC and Devroey P (2003) Abnormal endometrial development occurs during the luteal phase of non supplemented donor cycles treated with recombinant follicle-stimulating hormone and gonadotropin-releasing hormone antagonists. Fertil Steril 80, 464466.[CrossRef][ISI][Medline]
Nuojua-Huttunen S, Tomas C, Bloigu R, Tuomivaara L and Martikainen H (1999) Intrauterine insemination treatment in subfertility: an analysis of factors affecting outcome. Hum Reprod 14, 698703.
Olivennes F, Cunha-Filho JS, Fanchin R, Bouchard P and Frydman R (2002) The use of GnRH antagonists in ovarian stimulation. Hum Reprod Update 8, 279290.
Osuna C, Matorras R, Pijoan JI and Rodríguez-Escudero J (2004) One versus two inseminations per cycle in intrauterine insemination with sperm from patients' husbands: a systematic review of the literature. Fertil Steril 82, 1724.[CrossRef][ISI][Medline]
Ragni G, Vegetti W, Baroni E, Colombo M, Arnoldi M, Lombroso G and Crosignani PG (2001) Comparison of luteal phase profile in gonadotrophin stimulated cycles with or without a gonadotrophin-releasing hormone antagonist. Hum Reprod 16, 22582262.
Ragni G, Somigliana E and Vegetti W (2004) Timing of intrauterine insemination: where are we? Fertil Steril 82, 2526.[CrossRef][ISI][Medline]
Reissmann T, Felberbaum R, Diedrich K, Engel J, Comaru-Schally AM and Schally AV (1995) Development and applications of luteinizing hormone-releasing hormone antagonists in the treatment of infertility: an overview. Hum Reprod 10, 19741981.[Abstract]
Ricciarelli E, Sánchez M, Martínez M, Andrés L, Cuadros J and Hernández ER (2003) Impact of the gonadotropin-releasing hormone antagonist in oocyte donation cycles. Fertil Steril 79, 14611463.[CrossRef][ISI][Medline]
Tur R, Barri PN, Coroleu B, Buxaderas R, Martínez F and Balasch J (2001) Risk factors for high-order multiple implantation after ovarian stimulation with gonadotropins: evidence from a large series of 1878 consecutive pregnancies in a single centre. Hum Reprod 16, 21242129.
Submitted on June 7, 2004; resubmitted on August 6, 2004; accepted on October 15, 2004.
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