pure.uva.nl€¦ · mohamed abdel fattah mahmoud youssef 2016 ovarian stimulation in ivf in...

UvA-DARE is a service provided by the library of the University of Amsterdam (http://dare.uva.nl)

UvA-DARE (Digital Academic Repository)

Ovarian stimulation in IVF in relation to ovarian response

Youssef, M.A.F.M.

Link to publication

Citation for published version (APA):Youssef, M. A. F. M. (2016). Ovarian stimulation in IVF in relation to ovarian response.

General rightsIt is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s),other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons).

Disclaimer/Complaints regulationsIf you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, statingyour reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Askthe Library: https://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam,The Netherlands. You will be contacted as soon as possible.

Download date: 01 Feb 2021

https://dare.uva.nl/personal/pure/en/publications/ovarian-stimulation-in-ivf-in-relation-to-ovarian-response(22861fe5-05b9-40cf-8e91-e1bd7bad74b6).html

Mohamed Abdel Fattah Mahmoud Youssef 2016


Ovarian stim

ulation in IVF in relation to ovarian response

Moham

med A

bdel Fattah Mahm

oud Youssef

INVITATIONto attend the public defense

of the thesis entitled:

OVARIAN STIMULATION IN IVF IN RELATION TO

OVARIAN RESPONSE

byMohamed Abdel Fattah

Mahmoud Youssef

on Wednesday2 November 2016

at 11:00 a.m.

in the Lutherse Kerk, Aula of the University

of Amsterdam, Singel 411, Amsterdam

reception on siteafter the promotion


Mohamed Abdel Fattah Mahmoud Youssef

Ovarian stimulation in IVF in relation to ovarian responsePhD-thesis, University of Amsterdam, The Netherlands

© 2016 Mohamed Abdel Fattah Mahmoud YoussefAll rights reserved. No parts of this publication may be reproduced in any form without permission of the author.

The printing of this thesis was supported by: Stichting gynaecologische endocrinologie en kunstmatige voortplanting, Amsterdam

The thesis was prepared at the Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Academic Medical Center, University of Amsterdam, the Netherlands and at the Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Egypt.

Cover: Cairo University, website of Cairo UniversityLay-out: Mohamed Abdel Fattah Mahmoud YoussefPrinted by: GVO drukkers & vormgevers BVISBN: 978-94-6332-093-1


ACADEMISCH PROEFSCHRIFT

ter verkrijging van de graad van doctor

aan de Universiteit van Amsterdam

op gezag van de Rector Magnificus

prof.dr.ir.K.I.J. Maex

ten overstaan van een door het College voor Promoties ingestelde commissie,

in het openbaar te verdedigen in de Aula der Universiteit

op woensdag 2 november 2016, te 11:00 uur

door

Mohamed Abdel Fattah Mahmoud Youssef

geboren te Giza, Egypte

Promotiecommissie:

Promotores: Prof. dr. F. van der Veen Universiteit van AmsterdamProf. dr. H.G. Al-Inany Cairo University

Copromotores: Dr. M.H. Mochtar Universiteit van AmsterdamDr. M. van Wely Universiteit van Amsterdam

Overige leden: Prof. dr. F.J.M. Broekmans Universiteit UtrechtProf. dr. E.A. Elgindy Zagazig UniversityProf. dr. M. Goddijn Universiteit van AmsterdamDr. Y. Khalaf Guy's and St Thomas' HospitalProf. dr. C.B. Lambalk Vrije Universiteit Amsterdam

Faculteit der Geneeskunde

In memory of my mother

Contents

Chapter 1 General introduction and outline of thesis 9

Chapter 2 Gonadotrophin-releasing hormone antagonists for assisted reproductive technology

Al-Inany HG, Youssef MA, Ayeleke RO, Brown J, Lam WS, Broekmans FJ.

Cochrane Database Syst Rev. 2016; 4:CD001750.

20

Chapter 3 Can dopamine agonist at a low dose reduce ovarian hyperstimulation syndrome in women at risk undergoing ICSI treatment cycles? A randomized controlled studyShaltout A, Shohyab A, Youssef MA.

Eur J Obstet Gynecol Reprod Biol. 2012; 165:254-8.

64

Chapter 4 Can dopamine agonists reduce the incidence and severity of OHSS in IVF/ICSI treatment cycles? A systematic review and meta-analysisYoussef MA, van Wely M, Hassan MA, Al-Inany HG, Mochtar M, Khattab S, van

der Veen F.

Hum Reprod Update. 2010; 16:459-66.

77

Chapter 5 Gonadotropin-releasing hormone agonist versus HCG for oocyte triggering in antagonist-assisted reproductive technologyYoussef MA, van der Veen F, Al-Inany HG, Mochtar MH, Griesinger G, Nagi

Mohsen M, Aboulfoutouh I, van Wely M.

Cochrane Database Syst Rev. 2014;(10):CD008046.

93

Chapter 6 Volume expanders for the prevention of ovarian hyperstimulation syndromeYoussef MAFM, Mourad S

Cochrane Database Syst Rev. 2016 ;( 7):CD001302.

127

Chapter 7 Low doses of gonadotropins in IVF cycles for women with poor ovarian reserve: Systematic review and meta-analysis Youssef MA, van Wely M, Mochtar M , Fouda UM, van der Veen F.

submitted – under embargo

156

Chapter 8 Mild versus conventional ovarian stimulation for in-vitro fertilization treatment in women with poor ovarian reserve: a multicenter randomized controlled trial (PRIMA)Youssef MA, van Wely M, Al-Inany HG, Mochtar MH, Madani T, Jahangiri N,

Khodabakhshi S, Risk A, Halabi M, El-mohamady M, Shaeer EK, Khattab S, van

der Veen F

Human Reproduction - accepted

189

Chapter 9 Summary 208

Chapter 10 Samenvatting 224

APPENDICES

List of co-authors and affiliations 241

List of publications 244

Portfolio 247

Acknowledgements 252

About the author 255

Chapter 1

General introduction

9

Introduction

Subfertility is defined as a failure to conceive after at least one year of regular unprotected

intercourse (Zegers-Hochschild et al., 2009). It affects approximately 10% of couples in their

reproductive lives (Boivin et al., 2007). After a basic fertility work up, about 25% of couples is

diagnosed with unexplained subfertility, 30% with mild male subfertility, 5 % with severe male

subfertility, 20 % with anovulation and in 20% of the couples other diagnoses as tubal

blockage, cervical subfertility, endometriosis and sexual disorders are made (Brands et al.,

2010).

The introduction of medically assisted reproduction (MAR) has provided millions of couples

with hope. MAR consists of ovulation induction, intrauterine insemination (IUI) with or without

ovarian stimulation, and in vitro fertilization (IVF) with or without assisted fertilization (ICSI).

In IVF, ovarian stimulation with gonadotropins is an integral part of the treatment. It has been

introduced with the aim of increasing the number of embryos to compensate for poor embryo

quality, but is now being used to enable the selection of the best embryo for fresh transfer

and the cryopreservation of surplus embryos (Fauser et al., 2005). Currently, stimulation

protocols involving high doses of exogenous gonadotropins, combined with gonadotropin

releasing hormone (GnRH) analogues for the prevention of premature LH peaks are the

most frequently used protocols (Macklon et al., 2006).

The oocyte yield after these protocols depends on the follicle pool; in women with a normal

or an elevated ovarian reserve, high doses can provoke an excessive ovarian response with

subsequent ovarian hyperstimulation syndrome (OHSS) (Verberg et al., 2009). On the other

hand, for women with a so called ‘poor’ ovarian reserve, the yield of oocytes can be very low,

which jeopardizes outcome (de Boer et al., 2004). Thus, it is important to study stimulation

protocols to see whether live birth rates can be improved and the risk of OHSS can be

decreased.

OHSS is one of the major concerns in IVF (Kupka et al., 2014). Severe OHSS affects 1% of

women who undergo ovarian stimulation and IVF. It is a broad spectrum of signs and

symptoms that include abdominal distention and discomfort, enlarged ovaries, ascites and

other complications of enhanced vascular permeability (Ferrero et al., 2014). The exact

pathophysiology of OHSS remains unknown, but increased capillary permeability with the

resulting loss of fluid into the third space is common to the syndrome. Administration of

human chorionic gonadotrophin (hCG) for final follicle maturation and triggering of ovulation

appears to be the pivotal stimulus in a susceptible patient, by releasing vasoactive–

angiogenic substances such as VEGF from the ovary.

10

As the treatment of OHSS involves supportive management like antiemetics, analgesics,

fluid intake and paracentesis while the condition slowly improves, the mainstay of

management of women at risk of OHSS resolves around the prevention of this complication

in the first instance. By identifying women at risk, several preventive approaches have been

suggested to reduce the risk of OHSS; these approaches could be divided into primary and

secondary. Primary prevention includes individualized ovarian stimulation protocols with mild

doses of gonadotropins (Heijnen et al., 2007; Karimzadeh et al., 2010; Casano et al., 2012;

Rinaldi et al., 2014), use of GnRH antagonists (Onofriescu et al., 2013; Ozmen et al., 2014;

Xing et al., 2015) and in vitro maturation (Yu et al., 2012; Das et al., 2014; Walls et al., 2015).

Secondary prevention includes all strategies directed to counteract an excessive ovarian

response, ie cycle cancellation (Rizk & Aboulghar 1991), coasting (Sher et al., 1995; Kovács

et al., 2006; D'Angelo et al.,2011), ovulation triggering by low doses of HCG (Kosmas et al.,

2009; Tiboni et al.,2016) or by a GnRH agonist (Gülekli et al., 2015; Casper RF 2015),

dopamine agonist administration around the time of follicle aspiration (Baumgarten et al.,

2013; Kasum et al., 2014; Leitao et al., 2014); intravenous volume expanders administration

at the time of follicle aspiration (Gokmen et al., 2001) and cryopreservation of oocytes or

embryos (Boothroyd et al., 2015; Borges et al., 2016).

The second major concern in current IVF practice is a poor response to ovarian stimulation,

which occurs in 26% of IVF cycles. Worldwide, more and more women are having their first

child later in life (Mathews and Hamilton, 2009). This delayed child bearing has major

repercussions on reproductive function, such as subfertility based on diminished ovarian

reserve.

Poor ovarian response was – until 2011- defined in numerous ways based on different

diagnostic tests or patient characteristics; i.e. female age, basal follicle stimulating hormone

(FSH) level, anti-mullerian hormone (AMH) level, basal antral follicle count (AFC), ovarian

response to stimulation as number of mature follicles or peak estradiol level, dose of

gonadotropins used, and number of oocytes at follicle aspiration. Since 2011, the Bologna

criteria have been established to define poor ovarian response. This diagnosis can be made

when at least two of the following three features are present: advanced maternal age or any

other risk factor for poor ovarian response, a previous poor ovarian response or an abnormal

ovarian reserve test (Ferraretti et al., 2011) Poor response is thus the clinical manifestation

of a poor ovarian reserve.

IVF is now the treatment of choice in older women and it is estimated that 37% of all IVF

cycles are performed in these women (Kupka et al., 2014; Oudendijk et al., 2012; NICE

guidelines 2013). Currently, the conventional ovarian stimulation regimen for women with

11

poor ovarian reserve regardless of their age includes high doses of FSH or HMG - up to 600

IU/day- combined with various protocols of GnRH analogues to try and achieve high follicular

recruitment (Tarlatzis et al., 2003; Shanbhag et al., 2007; Pandian et al., 2010; Masschaele

et al., 2012; Bosdou et al., 2012). Nevertheless, despite these high doses of gonadotropins,

oocyte yield remains poor and cancellation rates are high (Lekamge et al., 2008; Dercourt et

al., 2016). This is due to a patient factor which is completely unrelated to ovarian stimulation

per se (Paulson et al., 2016). In women of advanced age, it reflects a physiologic decline in

ovarian reserve of primordial follicles, while in young women a poor response to ovarian

stimulation reflects a pathologic decline in number and quality of primordial follicles (de Boer

et al., 2004; Eltoukhy et al., 2002; Lawson et al., 2003).

Over the years several mild ovarian stimulation approaches have been suggested as

alternatives for women with poor ovarian reserve, aiming at reducing the dose of

gonadotropins or shorten the duration of stimulation using oral compounds such as

antiestrogens or aromatase inhibitors (Nargund et al., 2007; Karimzadeh et al., 2011; Yoo et

al., 2011; Eftekhar et al., 2014; Ozcan et al., 2014). Oral compounds such as clomiphene

citrate have been used for decades as an adjunct to increase the pituitary FSH secretion by

reducing estrogen negative feedback (Clark & Markaverich 1981). By this mechanism,

clomiphene citrate reduces the required amount of gonadotropins for stimulation. The

alternative adjunct, aromatase inhibitors, inhibits the aromatase activity in granulosa cells

and thereby increases the intra-ovarian concentration of androgens by blocking the

aromatization to estrogen; the lower estrogen then triggers the pituitary gland to an increase

in FSH release. (Mitwally and Casper 2002). Apart from lower costs, it has been proven that

mild ovarian stimulation in the general population gives rise to improved embryo quality and

implantation an increased proportion of euploid embryos and reduced drop-out rates

(Hohmann et al., 2003, Baart et al., 2007, Verberg et al., 2009).

Background of the research described in the thesis

In 2009, when we started the studies that led to this thesis, OHSS was a great challenge and

although there were a huge number of interventions available, the evidence to support one

over the other was limited. Thus, we set out to perform a series of systematic reviews and

meta-analyses to evaluate the most widely used pharmacologic interventions at that time like

GnRH antagonists, dopamine agonist supplementation, GnRH agonist trigger for final oocyte

maturation trigger and intravenous fluid administration. Dopamine agonist was one of the

most promising of these interventions, so we a set out to perform a randomized controlled

trial evaluating the lowest possible dose of cabergoline in two hundred women at risk to

develop OHSS.

12

At the same time, mild ovarian stimulation in IVF was becoming more and more a topic of

research in women with poor ovarian reserve. The studies so far on mild stimulation

protocols were of limited value since they had included small numbers of women, were of

poor methodological quality and used surrogate end-points such as number of oocytes or

embryos.

We therefore designed a multicenter randomized controlled trial to explore the possible

beneficial effect of mild ovarian stimulation in women with poor ovarian reserve undergoing

IVF, defined as women with a female age ≥ 35 years, a raised basal FSH level > 10 IU/ml

irrespective of age, a low antral follicular count of less than 5 follicles or poor ovarian

response or cycle cancellation during a previous IVF cycle irrespective of age. We defined

poor ovarian response in a previous cycle as an oocyte yield ≤ 5. To also provide the wider

picture, we set out to perform a systematic review and meta-analysis about the most recent

evidence summarizing randomized controlled trials comparing mild ovarian stimulation to

conventional ovarian stimulation in women with poor ovarian reserve.

Outlines of the thesis

The studies presented in this thesis focus on improving safety and effectiveness of IVF

outcomes by evaluating two extremes of the spectrum of ovarian response - OHSS and poor

ovarian response- to ovarian stimulation.

In chapter 2, we present a Cochrane systematic review on the effectiveness and safety of

gonadotropin-releasing hormone (GnRH) antagonists compared with the standard long

protocol of GnRH agonists for controlled ovarian hyperstimulation in assisted conception

cycles. The review included 73 RCTs, totalling 12212 women. Primary outcome measure of

effectiveness was live birth rate and primary outcome measure of safety was OHSS

incidence. Secondary outcome measures were ongoing pregnancy rate, clinical pregnancy

rate, miscarriage rate and cycle cancellation rate.

In chapter 3, we report a randomized clinical trial which we designed to evaluate whether a

strategy of adding a dopamine agonist to the standard ovarian stimulation in IVF in 200

women at risk to develop OHSS, results in a lower incidence of OHSS. The primary outcome

measure was reduction of the overall incidence of OHSS and secondary outcome measures

included severe and mild to moderate OHSS, early and late OHSS, number of retrieved

oocytes, number of mature oocytes, hospitalization rate due to severe OHSS, fertilization

rate, clinical pregnancy rate, live birth rate, and incidence of congenital anomalies.

13

In chapter 4, we present the findings of a systematic review on the effectiveness and safety

of the dopamine agonist cabergoline for reducing the risk of development of OHSS in 570

women at high risk. Secondary outcomes were pregnancy rates and miscarriages rates.

In chapter 5, we present a Cochrane review on the effectiveness and safety of GnRH

agonists in comparison with HCG for triggering final oocyte maturation in IVF and ICSI for

women undergoing COH in a GnRH antagonist protocol. We included 17 RCTs, totalling

1847 women. Primary outcome measure of effectiveness was live birth rate and primary

outcome measure of safety was OHSS. Secondary outcome measures were ongoing

pregnancy rates, clinical pregnancy rates and miscarriage rate.

In chapter 6, we present a Cochrane review on the effectiveness and safety of the

administration of intravenous fluids such as albumin, hydroxyethyl starch, Haemaccel® and

dextran in the prevention of severe ovarian hyperstimulation syndrome in IVF or ICSI

treatment cycles. We included nine RCTs, totalling 2147 women. Primary outcome measure

was the incidence of severe OHSS and secondary outcomes were pregnancy rates and

adverse events.

In chapter 7, we report the findings of a systematic review on the effectiveness of mild

ovarian stimulation IVF for treating women with poor ovarian reserve. We included 18 RCTs

totaling 1987 women. The primary outcome measure was ongoing pregnancy rate and the

secondary outcome measures were clinical pregnancy rate, live birth rate, duration of

gonadotropins stimulation, total dose of gonadotropins, number of cumulus–oocytes

complexes (COCs) retrieved, number of metaphase II oocytes, number of embryos obtained,

endometrial thickness on the day of hCG and cycle cancellation rate due to poor response.

In chapter 8, we report on a randomized clinical trial which we designed to evaluate the

ongoing pregnancy rates in 394 women with poor ovarian reserve receiving one cycle of IVF

with a mild ovarian stimulation strategy compared to one cycle of a conventional ovarian

stimulation. Primary outcome measure was ongoing pregnancy rate and secondary outcome

measures included clinical pregnancy, biochemical pregnancy, early pregnancy loss, number

of oocytes retrieved, number of metaphase II oocytes, fertilization rate, number of embryos

obtained, number of embryo transfers, total FSH/HMG doses used for ovarian stimulation,

cancellation rate and drop-out rate.

14

References

• Baart EB, Martini E, Eijkemans MJ, Van Opstal D, Beckers NG, Verhoeff A, Macklon NS, Fauser BC. Milder ovarian stimulation for in-vitro fertilization reduces aneuploidy in the human preimplantation embryo: a randomized controlled trial. Hum Reprod. 2007; 22(4):980-8.

• Baumgarten M, Polanski L, Campbell B, Raine-Fenning N. Do dopamine agonists prevent or reduce the severity of ovarian hyperstimulation syndrome in women undergoing assisted reproduction? A systematic review and meta-analysis. Hum Fertil 2013; 16(3):168-74.

• Boivin J, Bunting L, Collins JA, Nygren KG. International estimates of infertilityprevalence and treatment-seeking: potential need and demand for infertility medical care. Hum Reprod. 2007; 22(6):1506-12.

• Bosdou JK, Venetis CA, Kolibianakis EM, Toulis KA, Goulis DG, Zepiridis L, Tarlatzis BC. The use of androgens or androgen-modulating agents in poor responders undergoing in vitro fertilization: a systematic review and meta-analysis. Hum Reprod Update. 2012; 18(2):127-45.

• Brandes M, Hamilton CJ, de Bruin JP, Nelen WL, Kremer JA The relative contribution of IVF to the total ongoing pregnancy rate in a subfertile cohort. Hum Reprod. 2010; 25(1):118-26.

• Boothroyd C, Karia S, Andreadis N, Rombauts L, Johnson N, Chapman M; Australasian CREI Consensus Expert Panel on Trial evidence (ACCEPT) group. Consensus statement on prevention and detection of ovarian hyperstimulation syndrome. Aust N Z J Obstet Gynaecol. 2015; 55(6):523-34.

• Borges E Jr, Braga DP, Setti AS, Vingris LS, Figueira RC, Iaconelli A Jr. Strategies for the management of OHSS: Results from freezing-all cycles. JBRA Assist Reprod. 2016 1; 20(1):8-12.

• Brigham SA, Conlon C and Farquharson RG. A longitudinal study of pregnancy outcome following ovarian reserve and IVF outcome. Hum Reprod, 1999; 14:2868-2871.

• Casano S, Guidetti D, Patriarca A, Pittatore G, Gennarelli G, Revelli A. MILD ovarian stimulation with GnRH-antagonist vs. long protocol with low dose FSH for non-PCO high responders undergoing IVF: a prospective, randomized study including thawing cycles. J Assist Reprod Genet 2012; 29 (12): 1343–1351.

• Casper RF. Introduction: Gonadotropin-releasing hormone agonist triggering of final follicular maturation for in vitro fertilization. Fertil Steril. 2015; 103(4):865-6.

• Clark JH, Markaverich BM. The agonistic-antagonistic properties of clomiphene: a review. Pharmacol Ther. 1981; 15(3):467-519.

15

• D'Angelo A, Brown J, Amso NN. Coasting (withholding gonadotrophins) for preventing ovarian hyperstimulation syndrome. Cochrane Database Syst Rev. 2011 15;( 6):CD002811.

• Das M, Son WY, Buckett W, Tulandi T, Holzer H. In-vitro maturation versus IVF with GnRH antagonist for women with polycystic ovary syndrome: treatment outcome and rates of ovarian hyperstimulation syndrome. Reprod Biomed Online. 2014;29(5):545-51.

• de Boer EJ, Den Tonkelaar I, Burger CW, Looman CW, van Leeuwen FE, te Velde ER; The number of retrieved oocytes does not decrease during consecutive gonadotrophin-stimulated IVF cycles. OMEGA project group. Hum Reprod. 2004; 19(4):899-904.

• Dercourt M, Barriere P, Freour T. High doses of gonadotropins for controlled ovarian hyperstimulation: A case-control study. Gynecol Obstet Fertil. 2016; 44(1):29-34.

• Eftekhar M, Mohammadian F, Davar R, Pourmasumi S. Comparison of pregnancy outcome after letrozole versus clomiphene treatment for mild ovarian stimulation protocol in poor responders. Iran J Reprod Med. 2014; 12(11):725-30.

• El-Toukhy T, Khalaf Y, Hart R, Taylor A, Braude P Young age does not protect against the adverse effects of reduced ovarian reserve--an eight year study. Hum Reprod. 2002; 17(6):1519-24.

• Fauser BC, Devroey P, Macklon NS Multiple birth resulting from ovarian stimulation for subfertility treatment. Lancet. 2005; 365(9473):1807-16.

• Ferraretti AP, La Marca A, Fauser BC, Tarlatzis B, Nargund G, Gianaroli L, ESHRE Working Group on Poor Ovarian Response Definition. ESHRE consensus on the definition of ‘poor response’ to ovarian stimulation for in vitro fertilization: the Bologna criteria. Hum Reprod 2011; 26 (7):1616–1624.

• Ferrero H, Garcı´a-Pascual CM, Go´mez R, Delgado-Rosas F, Cauli O, Simón C, Gaytán F, Pellicer A . Dopamine receptor 2 activation inhibits ovarian vascular endothelial growth factor secretion in vitro: implications for treatment of ovarian hyperstimulation syndrome with dopamine receptor 2 agonists. Fertil Steril 2014; 101(5):1411–1418.

• Gokmen, O. Ugur M, Ekin M, Keles G, Turan C, Oral H. Intravenous albumin versus hydroxyethyl starch for the prevention of ovarian hyperstimulation in an in vitro fertilization programme: a prospective randomized placebo controlled study. Eur J Obstet Gynecol Reprod Biol 2001; 96 (2), 187–92.

• Gülekli B, Göde F, Sertkaya Z, Işık AZ. Gonadotropin-releasing hormone agonist triggering is effective, even at a low dose, for final oocyte maturation in ART cycles: Case series.J Turk Ger Gynecol Assoc. 2015 1; 16(1):35-40.

• Heijnen EM, Eijkemans MJ, De Klerk C, Polinder S, Beckers NG, Klinkert ER, Broekmans FJ, Passchier J, Te Velde ER, Macklon NS, Fauser BC. A mild treatment

16

strategy for in-vitro fertilisation: a randomised non-inferiority trial. Lancet 2007; 369 (9563): 743–749.

• Hohmann FP, Macklon NS, Fauser BC. A randomized comparison of two ovarian stimulation protocols with gonadotropin-releasing hormone (GnRH) antagonist cotreatment for in vitro fertilization commencing recombinant follicle-stimulating hormone on cycle day 2 or 5 with the standard long GnRH agonist protocol. J Clin Endocrinol Metab. 2003; 88(1):166-73.

• Karimzadeh MA, Ahmadi S, Oskouian H, Rahmani E. Comparison of mild stimulation and conventional stimulation in ART outcome. Arch Gynecol Obstet 2010; 281(4): 741–746.

• Karimzadeh MA, Mashayekhy M, Mohammadian F, Moghaddam FM Comparison of mild and microdose GnRH agonist flare protocols on IVF outcome in poor responders. Arch Gynecol Obstet. 2011; 283(5):1159-64.

• Kasum M, Vrčić H, Stanić P, Ježek D, Orešković S, Beketić-Orešković L, Pekez M Dopamine agonists in prevention of ovarian hyperstimulation syndrome. Gynecol Endocrinol. 2014; 30(12):845-9.

• Kol S, Homburg R, Alsbjerg B, Humaidan P. The gonadotropin-releasing hormone antagonist protocol--the protocol of choice for the polycystic ovary syndrome patient undergoing controlled ovarian stimulation. Acta Obstet Gynecol Scand. 2012; 91(6):643-7.

• Kosmas IP, Zikopoulos K, Georgiou I, Paraskevaidis E, Blockeel C, Tournaye H, Van Der Elst J, Devroey P. Low-dose HCG may improve pregnancy rates and lower OHSS in antagonist cycles: a meta-analysis. Reprod Biomed Online. 2009; 19(5):619-30.

• Kovács P, Mátyás S, Kaali SG Effect of coasting on cycle outcome during in vitro fertilization/intracytoplasmic sperm injection cycles in hyper-responders. Fertil Steril. 2006; 85(4):913-7.

• Kupka MS, Ferraretti AP, de Mouzon J Erb K, D'Hooghe T, Castilla JA, Calhaz-Jorge C, De Geyter C, Goossens V. Assisted reproductive technology in Europe, 2010: results generated from European registers by ESHRE. Hum Reprod 2014; 29 (10):2099–2113.

• Lawson R, El-Toukhy T, Kassab A, Taylor A, Braude P, Parsons J, Seed P. Poor response to ovulation induction is a stronger predictor of early menopause than elevated basal FSH: a life table analysis. Hum Reprod. 2003; 18(3):527-33.

• Lekamge DN, Lane M, Gilchrist RB, Tremellen KP. Increased gonadotrophin stimulation does not improve IVF outcomes in patients with predicted poor ovarian reserve. J Assist Reprod Genet. 2008; 25 (11-12):515–21.

• Leitao VM, Moroni RM, Seko LM, Nastri CO, Martins WP. Cabergoline for the prevention of ovarian hyperstimulation syndrome: systematic review and meta-analysis of randomized controlled trials. Fertil Steril. 2014; 101(3):664-75.

17

• Macklon NS, Stouffer RL, Giudice LC, Fauser BC .The science behind 25 years of ovarian stimulation for in vitro fertilization. Endocr Rev. 2006; 27(2):170-207.

• Masschaele T, Gerris J, Vandekerckhove F, De Sutter P. Does transferring three or more embryos make sense for a well-defined population of infertility patients undergoing IVF/ICSI? Facts Views Vis Obgyn. 2012; 14 (1):51-8.

• Mathews, TJ and Hamilton BE. Delayed childbearing: More women Are Having Their First Child Later in Life NCHS Data Brief 2009; Number 21.

• Mitwally MF, Casper RF. Aromatase inhibition improves ovarian response to follicle-stimulating hormone in poor responders. Fertil Steril. 2002; 77(4):776-80.

• Nargund G, Fauser BC, Macklon NS, Ombelet W, Nygren K, Frydman R, Rotterdam ISMAAR Consensus Group on Terminology for Ovarian Stimulation for IVF. The ISMAAR proposal on terminology for ovarian stimulation for IVF. Hum Reprod 2007; 22 (11):2801‑4.

• National Institute for Health and Clinical Excellence (2013) Updated NICE guidelines revise treatment recommendations for people with fertility problems. NICE guidelines [CG156].

• Onofriescu A, Bors A, Luca A, Holicov M, Onofriescu M, Vulpoi C GnRH Antagonist IVF Protocol in PCOS. Curr Health Sci J. 2013; 39(1):20-5.

• Oudendijk JF, Yarde F, Eijkemans MJ, Broekmans FJ, Broer SL. The poor responder in IVF: is the prognosis always poor? a systematic review. Hum Reprod Update 2012; 18(1): 1–11.

• Ozcan Cenksoy P, Ficicioglu C, Kizilkale O, Suhha Bostanci M, Bakacak M, Yesiladali M, Kaspar C. The comparison of effect of microdose GnRH-a flare-up, GnRH antagonist/aromatase inhibitor letrozole and GnRH antagonist/clomiphene citrate protocols on IVF outcomes in poor responder patients. Gynecol Endocrinol. 2014; 30(7):485-9.

• Ozmen B, Sükür YE, Seval MM, Ateş C, Atabekoğlu CS, Sönmezer M, Berker B. Dual suppression with oral contraceptive pills in GnRH antagonist cycles for patients with polycystic ovary syndrome undergoing intracytoplasmic sperm injection. Eur J Obstet Gynecol Reprod Biol. 2014; 183:137-40. Pandian Z, McTavish AR, Aucott L, Hamilton MP, Bhattacharya S Interventions for 'poor responders' to controlled ovarian hyper stimulation (COH) in in-vitro fertilisation (IVF). Cochrane Database Syst Rev.2010 ;( 1):CD004379.

• Paulson RJ, Fauser BC, Vuong LT, Doody K Can we modify assisted reproductive technology practice to broaden reproductive care access? Fertil Steril. 2016; 105(5):1138-43.

• Rinaldi L, Lisi F, Selman H. Mild/minimal stimulation protocol for ovarian stimulation of patients at high risk of developing ovarian hyperstimulation syndrome. J Endocrinol Invest 2014; 37(1): 65–70.

18

• Rizk B, Aboulghar M. Modern management of ovarian hyperstimulation syndrome. Hum Reprod 1991; 6(8):1082–7.

• Shanbhag S, Aucott L, Bhattacharya S, Hamilton MA, McTavish AR. Interventions for poor responders' to controlled ovarian hyperstimulation (COH) in in-vitro fertilisation (IVF). Cochrane Database Syst Rev. 2007 ;( 1):CD004379.

• Sher G, Zouves C, Feinman M, Maassarani G. ‘Prolonged coasting’: an effective method for preventing severe ovarian hyperstimulation syndrome in patients undergoing in-vitro fertilization. Hum Reprod 1995; 10(12):3107–9.

• Tarlatsiz B.C, Zepiridis. L, Grimbizis. G and Bontis J, Clinical management of low ovarian response to stimulation for IVF: a systematic review, Hum Reprod Update 2003; 9(1). 61–76.

• Tiboni GM, Colangelo EC, Ponzano A. Reducing the trigger dose of recombinant hCG in high-responder patients attending an assisted reproductive technology program: an observational study. Drug Des Devel Ther. 2016; 10:1691-4.

• Verberg MF, Macklon NS, Nargund G, Frydman R, Devroey P, Broekmans FJ, Fauser BC. Mild ovarian stimulation for IVF. Hum Reprod Update. 2009; 15(1):13-29.

• Walls ML, Hunter T, Ryan JP, Keelan JA, Nathan E, Hart RJ. In vitro maturation as an alternative to standard in vitro fertilization for patients diagnosed with polycystic ovaries: a comparative analysis of fresh, frozen and cumulative cycle outcomes. Hum Reprod. 2015; 30(1):88-96.

• Xing W, Lin H, Li Y, Yang D, Wang W, Zhang Q. Is the GnRH Antagonist Protocol Effective at Preventing OHSS for Potentially High Responders Undergoing IVF/ICSI? PLoS One. 2015 15; 10(10):e0140286.

• Yoo JH, Cha SH, Park CW, Kim JY, Yang KM, Song IO, Koong MK, Kang IS, Kim HO. Comparison of mild ovarian stimulation with conventional ovarian stimulation in poor responders. Clin Exp Reprod Med. 2011; 38(3):159-63.

• Yu R, Lin J, Zhao JZ, Wang PY, Xiao SQ, Zhang W. Study on clinical effect on infertility women with polycystic ovary syndrome treated by in vitro maturation and in vitro fertilization-embryo transfer. Zhonghua Fu Chan Ke Za Zhi. 2012; 47(4):250-4.

• Zegers-Hochschild F, Adamson GD, de Mouzon J, Ishihara O, Mansour R, Nygren K, Sullivan E, van der Poel S; The International Committee for Monitoring Assisted Reproductive Technology (ICMART) and the World Health Organization (WHO) Revised Glossary on ART Terminology, 2009. Hum Reprod. 2009; 24(11):2683-7.

19

Chapter 2

Gonadotrophin- releasing hormone antagonists for

assisted reproductive technology.

Al-Inany HG, Youssef MA, Ayeleke RO, Brown J, Lam WS,

Broekmans FJ.

Cochrane Database Syst Rev. 2016; 4:CD001750.

20

Abstract

Background: Gonadotrophin-releasing hormone (GnRH) antagonists can be used to prevent

a luteinizing hormone (LH) surge during controlled ovarian hyperstimulation (COH) without

the hypo-oestrogenic side-effects, flare-up, or long down-regulation period associated with

agonists. The antagonists directly and rapidly inhibit gonadotrophin release within several

hours through competitive binding to pituitary GnRH receptors. This property allows their use

at any time during the follicular phase. Several different regimens have been described

including multiple-dose fixed (0.25 mg daily from day six to seven of stimulation), multiple-

dose flexible (0.25 mg daily when leading follicle is 14 to 15 mm), and single-dose (single

administration of 3 mg on day 7 to 8 of stimulation) protocols, with or without the addition of

an oral contraceptive pill. Further, women receiving antagonists have been shown to have a

lower incidence of ovarian hyperstimulation syndrome (OHSS). Assuming comparable

clinical outcomes for the antagonist and agonist protocols, these benefits would justify a

change from the standard long agonist protocol to antagonist regimens. This is an update of

Cochrane review first published in 2001, and previously updated in 2006 and 2011.

Objectives: To evaluate the effectiveness and safety of gonadotrophin-releasing hormone

(GnRH) antagonists compared with the standard long protocol of GnRH agonists for

controlled ovarian hyperstimulation in assisted conception cycles.

Search methods: We searched the Cochrane Menstrual Disorders and Subfertility Group

Trials Register (searched from inception to May 2015), the Cochrane Central Register of

Controlled Trials (CENTRAL) (The Cochrane Library, inception to 28 April 2015), Ovid

MEDLINE (1966 to 28 April 2015), EMBASE (1980 to 28 April 2015), PsycINFO (1806 to 28

April 2015), CINAHL (to 28 April 2015) and trial registers to 28 April 2015, and hand

searched bibliographies of relevant publications and reviews, and abstracts of major

scientific meetings, for example the European Society of Human Reproduction and

Embryology (ESHRE) and American Society for Reproductive Medicine (ASRM). We

contacted the authors of eligible studies for missing or unpublished data. The evidence is

current to 28 April 2015. Selection criteria: Two review authors independently screened the

relevant citations for randomised controlled trials (RCTs) comparing different GnRH agonist

versus GnRH antagonist protocols in women undergoing in vitro fertilisation (IVF) or

intracytoplasmic sperm injection (ICSI).

21

Data collection and analysis : Two review authors independently assessed trial eligibility

and risk of bias, and extracted the data. The primary review outcomes were live birth and

ovarian hyperstimulation syndrome (OHSS). Other adverse effects (miscarriage and cycle

cancellation) were secondary outcomes. We combined data to calculate pooled odds ratios

(ORs) and 95% confidence intervals (CIs). Statistical heterogeneity was assessed using the

I2 statistic. We assessed the overall quality of the evidence for each comparison using

GRADE methods.

Main results : We included 73 RCTs, with 12,212 participants, comparing GnRH antagonist

to long-course GnRH agonist protocols. The quality of the evidence was moderate:

limitations were poor reporting of study methods. There was no evidence of a difference in

live birth rate between GnRH antagonist and long course GnRH agonist (OR 1.02, 95% CI

0.85 to 1.23; 12 RCTs, n = 2303, I2= 27%, moderate quality evidence). The evidence

suggested that if the chance of live birth following GnRH agonist is assumed to be 29%, the

chance following GnRH antagonist would be between 25% and 33%.

GnRH antagonist was associated with lower incidence of any grade of OHSS than GnRH

agonist (OR 0.61, 95% C 0.51 to 0.72; 36 RCTs, n = 7944, I2 = 31%, moderate quality

evidence). The evidence suggested that if the risk of OHSS following GnRH agonist is

assumed to be 11%, the risk following GnRH antagonist would be between 6% and 9%.

There was no evidence of a difference in miscarriage rate per woman randomised between

GnRH antagonist group and GnRH agonist group (OR 1.03, 95% CI 0.82 to 1.29; 34 RCTs, n

= 7082, I2 = 0%, moderate quality evidence). With respect to cycle cancellation, GnRH

antagonist was associated with a lower incidence of cycle cancellation due to high risk of

OHSS (OR 0.47, 95% CI 0.32 to 0.69; 19 RCTs, n = 4256, I2 = 0%). However cycle

cancellation due to poor ovarian response was higher in women who received GnRH

antagonist than those who were treated with GnRH agonist (OR 1.32, 95% CI 1.06 to 1.65;

25 RCTs, n = 5230, I2 = 68%; moderate quality evidence).

Authors' conclusions

There is moderate quality evidence that the use of GnRH antagonist compared with long-

course GnRH agonist protocols is associated with a substantial reduction in OHSS without

reducing the likelihood of achieving live birth.

22

Introduction

Controlled ovarian hyperstimulation (COH) coupled with in vitro fertilisation (IVF) or

intracytoplasmic sperm injection (ICSI) was one of the major advances in the treatment of

subfertility in the second half of the 20th century. One aspect of COH-IVF or ICSI that

requires attention is the occurrence of a luteinizing hormone (LH) surge which may occur

prematurely, before the leading follicle reaches the optimum diameter for triggering ovulation.

Such premature LH surges prevent effective induction of multiple follicular maturation

patterns for a significant number of women.

Gonadotrophin-releasing hormone agonists (GnRH agonists) have played an important role

in reducing the incidence of premature LH surges by reversibly blocking pituitary

gonadotrophin secretion. As a result, the rates of cancellation of assisted conception cycles

are decreased and pregnancy rates increased (Albano 1996; Hughes 1992). However, the

use of GnRH agonists is not without disadvantages. Even though the standard long-course

GnRH agonist protocol proved to be the most efficacious protocol (Daya 2000) for the use of

GnRH agonists, it requires two to three weeks for desensitisation, with relatively high costs

due to an increased requirement for gonadotrophin injections, and the need for hormonal and

ultrasonographic measurements (Olivennes 1994).

A common complication associated with ovarian stimulation with exogenous gonadotrophins

is ovarian hyperstimulation syndrome (OHSS) (Mathur 2007). It usually occurs following a LH

surge or after exposure to human chorionic gonadotrophin (hCG) (Mozes 1965). Most cases

of OHSS are mild with few or no clinical consequences. However, severe cases occur

occasionally with serious morbidity and mortalities (Delvigne 2002). Gonadotrophin-releasing

hormone analogues (GnRH agonists and antagonists) stabilise the luteal phase thereby

preventing premature LH surges and reducing the risk of OHSS.

23

In 1999, gonadotrophin-releasing hormone antagonists (GnRH antagonist) were introduced

to the market to prevent LH surge, and it was assumed that GnRH antagonists might be a

more patient-friendly protocol than the mid-luteal GnRH agonist protocol. GnRH antagonists

cause immediate, reversible and dose-related inhibition of gonadotrophin release by

competitive blockade of the GnRH receptors in the pituitary gland, and therefore treatment

can be restricted to those days when a premature LH surge is likely to occur (Duijkers 1998;

Felberbaum 1995; Huirne 2007).

The first generation of GnRH antagonists was associated with allergic side-effects due to an

induced histamine release, which hampered the clinical development of these compounds.

Third generation GnRH antagonists such as ganirelix (NV Organon, Oss, the Netherlands)

and cetrorelix (ASTA-Medica, Frankfurt am Main, Germany) have resolved these issues and

are approved for clinical use (Olivennes 1998).

Two approaches have emerged in GnRH antagonist administration; the single-dose protocol,

in which one injection of GnRH antagonist (Cetrotide® 3 mg, Merck SeronoSA., Geneva,

Switzerland ) is administered in the late phase of ovarian stimulation and the multiple-dose

regimen, in which 0.25 µg of cetrorelix or ganirelix is administered daily from stimulation day

6 onwards (fixed regimen). A flexible regimen based on the follicular size, has since been

introduced to minimise the number and duration of GnRH antagonist injections (Huirne

2007).

In a natural ovulatory cycle, ovulation, the release of the dominant follicle from the ovary,

usually occurs about 36 hours after LH surge. In women undergoing controlled ovarian

stimulation (COS) during assisted reproductive technology (ART), certain agents are usually

administered to mimic the natural LH surge. Ultrasounds scan and blood oestrogen levels

are used to determine the day on which to administer the triggering agents. Ovulation

triggering agents include hCG and GnRH agonist. These agents have different modes of

action and their use might, therefore, differentially influence the effectiveness of GnRH

antagonists.

Applying GnRH antagonists for pituitary desensitisation during COH is expected to result in a

dramatic reduction in the duration of GnRH analogue treatment and to reduce the amount of

gonadotrophin needed for stimulation as compared with the long agonist protocol. Other

potential benefits include a lower risk of developing severe ovarian hyperstimulation

syndrome (OHSS) and avoidance of oestrogen deprivation symptoms (for example hot

flushes, sleep disturbances, headaches) frequently observed in the pre-stimulation phase of

a long agonist protocol. Whether the previously mentioned benefits justify a change in routine

24

treatment from the standard long-course GnRH agonist protocol to the GnRH antagonist

regimen depends on whether the clinical outcomes using these protocols are similar.

The first Cochrane review on this topic was published in 2001 and was updated in 2006 and

2011. As further RCTs have been published, this is a further update of the evidence on the

comparative effectiveness of GnRH antagonists versus GnRH agonists in women

undergoing COH-IVF or ICSI, with respect to reducing the risk of OHSS and cycle

cancellation while maintaining the live birth rate.

Objectives: To evaluate the effectiveness and safety of gonadotrophin-releasing hormone

(GnRH) antagonists compared with the standard long protocol of GnRH agonists for

controlled ovarian hyperstimulation in assisted conception cycles

Methods

Criteria for considering studies for this review

Types of studies: Only randomised controlled trials (RCTs) with a parallel design were

eligible for inclusion. Quasi-randomised trials were not included (e.g. studies with evidence of

inadequate sequence generation such as alternate days, patient numbers) as they are

associated with a high risk of bias. If cross-over studies, with cross-over occurring between

cycles were available, we would have included only the first cycle, before the cross-over.

Types of participants: Subfertile couples undergoing controlled ovarian hyperstimulation

(COH) as part of an IVF or ICSI programme using GnRH antagonists or long-course GnRH

agonist protocols for the prevention of premature LH surges.

Types of interventions : Pituitary suppression with GnRH antagonists (for example

cetrorelix, ganirelix) or long-course GnRH agonists together with ovarian stimulation with

recombinant or urinary human follicle stimulating hormone (hFSH) or human menopausal

gonadotrophin (hMG), or both, or clomiphene citrate as part of an IVF or ICSI treatment

cycles. Further, the use of oral contraceptive pill (OCP) pre-treatment did not constitute an

inclusion or exclusion criterion but rather was a variation in the protocols used.

Types of outcome measures

Primary outcomes:

• Live birth rate (LBR) per woman randomised, defined as delivery of a live fetus after

20 completed weeks of gestation.

25

• Ovarian hyperstimulation syndrome (OHSS) rate per woman randomised, with

grading as detected by clinical grading of OHSS, laboratory investigations (e.g.

haematocrit, haemoglobin, renal function) or imaging techniques (ovarian and

abdominal ultrasound, chest X-ray), or both: all women, moderate or severe OHSS.

Secondary outcomes

• Ongoing pregnancy rate (OPR) per woman randomised, defined as a pregnancy

beyond 12 weeks' gestation.

• Clinical pregnancy rate (CPR) per woman randomised, defined as the presence of a

gestational sac ± fetal heart beat at transvaginal ultrasound.

• Other adverse effects.

o Miscarriage rate per woman randomised: miscarriage is defined as pregnancy

loss before 20 weeks' gestation. Miscarriage rate per clinical pregnancy was

analysed as a secondary analysis).

o Cycle cancellation rate per woman randomised. Two types of cycle

cancellation were assessed in separate analyses: cycle cancellation due to

high risk of OHSS and cycle cancellation due to poor ovarian response.

Search methods for identification of studies: We searched for all published and

unpublished RCTs of GnRH antagonist versus the long-course GnRH agonist protocol in

women undergoing COH-IVF or ICSI using the following search strategy, without language

restriction and in consultation with the Gynaecology and Fertility Group (CGF) (formerly

known as Menstrual Disorders and Subfertility Group (MDSG)) Information Specialist. We

performed the most recent searches on 28 April 2015.

Electronic searches: The following electronic databases, trial registers and websites were

searched (from their inception).

• Menstrual Disorders and Subfertility Group (MDSG) Specialised Register (updated search from 2010 to 28 April 2015) (Appendix 1).

• Ovid Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library; Issue 4 2015) (updated search from 2010 to 28 April 2015) (Appendix 2).

• Ovid MEDLINE (updated search from 2010 to 28 April 2015) (Appendix 3). The MEDLINE search was based on the Cochrane Highly Sensitive Search Strategy (HSSS) for identifying randomised trials in MEDLINE: sensitivity-maximising version (Lefebvre 2011).

• Ovid EMBASE (updated search 2010 up to 28 April 2015) (Appendix 4). The EMBASE search was combined with the trial filter developed by the Scottish Intercollegiate Guidelines Network (SIGN) (http://sign.ac.uk/methodology/filters.html).

26

• Ovid PsycINFO (updated search from 2010 to 28 April 2015) (Appendix 5). The PsycINFO search was combined with the trial filter developed by the Scottish Intercollegiate Guidelines Network (SIGN) (http://sign.ac.uk/methodology/filters.html).

• EBSCO CINAHL (Cumulative Index to Nursing and Allied Health Literature) (Appendix 6).

• Trial registers for ongoing and registered trials: ISRCTN (http://www.isrctn.com/), ClinicalTrials.gov (https://clinicaltrials.gov/), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal (www.who.int/trialsearch/Default.aspx).

• DARE (Database of abstracts of reviews of effectiveness) in The Cochrane Library at http://onlinelibrary.wiley.com/o/cochrane/cochrane_cldare_articles_fs.html (for reference lists from relevant non-Cochrane reviews

• LILACS database http://lilacs.bvsalud.org/en/ (for trials from the Portuguese and Spanish speaking world)

• Citation indexes on the ISI Web of Science (http://ipscience.thomsonreuters.com/product/web-of-science/).

• LILACS (Latin American and Caribbean Health Sciences) (http://bases.bireme.br/cgi-bin/wxislind.exe/iah/online/?IsisScript=iah/iah.xis&base=LILACS&lang=i&form=F).

• PubMed (www.ncbi.nlm.nih.gov/pubmed/). The PubMed search was combined with the random control filter for PubMed.

• OpenGrey - http://www.opengrey.eu/ for unpublished literature from Europe.

Searching other resources: We also searched the reference lists of all known primary

studies, review articles, citation lists of relevant publications, abstracts of major scientific

meetings (for example of the European Society of Human Reproduction and Embryology

(ESHRE) and American Society for Reproductive Medicine (ASRM)). We contacted known

experts and personal contacts regarding any unpublished materials. In addition, we hand

searched appropriate journals. The list of journals is in the CGF Module, which can be found

in The Cochrane Library under BROWSE - 'By Review Group' - 'Cochrane Gynaecology and

Fertility Group' - then 'about this group' at the top of this page. We liaised with the CGF

Information Specialist to avoid duplication of hand searching.

Data collection and analysis

Selection of studies: After an initial screen of titles and abstracts retrieved by the search,

we retrieved the full texts of all potentially eligible studies. Two review authors (RA and JB)

independently examined these full-text articles for compliance with the inclusion criteria and

selected studies eligible for inclusion in the review. We contacted study investigators as

required, to clarify study eligibility. We resolved disagreements as to study eligibility by

27

discussion or by involving a third review author (MAY). We documented the selection

process with a “PRISMA” flow chart (Figure 1) (Moher 2009)

Data extraction and management: We developed and piloted a standardised data

extraction form for consistency and completeness. Three review authors (RA, JB or WSL)

independently performed data extraction with discrepancies resolved by discussion. The data

extraction forms included study demographics, patient characteristics and study risk of bias.

We included this information in the review and presented it in the tables 'Characteristics of

included studies' and 'Characteristics of excluded studies' according to the guidance given in

the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011a). Where

studies had multiple publications the review authors collated multiple reports of the same

study, so that each study rather than each report was the unit of interest in the review, and

such studies would have a single study ID with multiple references. We contacted trial

authors to request additional information or data. We also received a response from the

sponsoring pharmaceutical companies.

Assessment of risk of bias in included studies: Three authors (RA, JB and WSL)

independently assessed the risk of bias of the included trials using The Cochrane 'Risk of

bias' (RoB) tool (Higgins 2011b). The domains assessed were: (1) sequence generation (for

example; was the method used for allocation sequence adequately described?); (2)

allocation concealment (for example, was allocation adequately concealed?); (3) blinding of

participants, personnel and outcome assessors (for example; was knowledge of the allocated

intervention adequately prevented during the study?); (4) incomplete outcome data (for

example, were incomplete outcome data adequately addressed?); (5) selective outcome

reporting (for example, were reports of the study free of suggestion of selective outcome

reporting?); and (6) other sources of bias (for example, was the study apparently free of

other problems that could put it at a high risk of bias?). Other potential sources of bias

included baseline imbalances, source of funding, early stopping for benefit, and

appropriateness of cross-over design. We resolved disagreements by discussion or by

consulting a fourth review author. We described all judgments fully and presented the

conclusions in the 'Risk of bias' table (see the Characteristics of included studies table),

which was incorporated into the interpretation of review findings by means of sensitivity

analyses (see below). With respect to selective reporting, we sought published protocols and

compared the outcomes between the protocol and the final published study, but the searches

did not yield published protocols of any of the included studies. We took care to search for

within-trial selective reporting, such as non-reporting of obvious outcomes, or reporting them

in insufficient detail to allow for inclusion. Where identified studies failed to report the primary

28

outcomes of live birth and OHSS but did report interim outcomes such as pregnancy, we

undertook informal assessment as to whether the interim values (e.g. pregnancy rates) were

similar to those reported in studies that also reported live birth.

Measures of treatment effect: We only reported dichotomous data (e.g. live birth rates) in

this review and we used the numbers of events in the control and intervention groups of each

study to calculate Mantel-Haenszel odds ratios (ORs). We reversed the direction of effect of

individual studies, if required, to ensure consistency across trials. We presented 95%

confidence intervals (CIs) for all outcomes. Where data to calculate ORs were not available,

we utilised the most detailed numerical data available that facilitated similar analyses of

included studies (e.g. test statistics, P values). We compared the magnitude and direction of

effect reported by studies with how they were presented in the review, taking account of

legitimate differences (Deeks 2011).

Unit of analysis issues: The primary analysis was per woman randomised. We also

included per clinical pregnancy data for miscarriage. we contacted authors of studies that did

not allow valid analysis of data (e.g. 'per cycle' data) and requested ‘per woman’ data. If no

‘per woman’ data was provided after contact, we did not include such studies in meta-

analyses.

Dealing with missing data: We analysed the data on an intention-to-treat basis as far as

possible and made attempts to obtain missing data from the original trialists. Initially, we

planned to undertake imputation of individual values for the primary outcomes if we were

unable to obtain missing data from the original trialists but no data imputation was

undertaken in the end and we analysed only the available data.

Assessment of heterogeneity: We considered whether the clinical and methodological

characteristics of the included studies were sufficiently similar for meta-analysis to provide a

clinically meaningful summary. We assessed statistical heterogeneity by the measure of the

I2 statistic (Higgins 2003). We took an I2 statistic measurement greater than 50% to indicate

substantial heterogeneity (Deeks 2011).

Assessment of reporting biases: In view of the difficulty of detecting and correcting for

publication bias and other reporting biases, the review authors aimed to minimise their

potential impact by ensuring a comprehensive search for eligible studies and by being alert

for duplication of data. We used a funnel plot to explore the possibility of small study effects

(a tendency for estimates of the intervention effect to be more beneficial in smaller studies)

(Egger 1997).

29

Data synthesis: Where the studies were sufficiently similar, we combined the data using a

fixed-effect analysis (on the assumption that the underlying effect size was the same for all

the trials in the analysis) comparing GnRH antagonist versus long course GnRH agonist. An

increase in the odds of a particular outcome that were likely to be beneficial (e.g. live birth) or

detrimental (e.g. adverse effects), were displayed graphically in the meta-analyses to the

right of the centre-line and a decrease in the odds of an outcome to the left of the centre-line.

All analyses were performed using Review Manager software (RevMan) (RevMan 2014).

Subgroup analysis and investigation of heterogeneity: Where there were sufficient data

we performed subgroup analyses for the following variables, for live birth and pregnancy

outcomes.

• Triggering agent used for oocyte maturation (hCG, GnRH agonist, mixed (hCG/GnRH

agonist) or unknown agent)

• Minimal or standard level of stimulation

Where we detected substantial heterogeneity, we explored possible explanations in

sensitivity analyses. We took any statistical heterogeneity into account when interpreting the

results, especially where there was any variation in the direction of effect.

Sensitivity analysis: We conducted sensitivity analyses for LBR and OPR to determine

whether the conclusions were robust to arbitrary decisions made regarding the eligibility and

analysis (Moher 1999). These analyses included consideration of whether the review

conclusions would have differed if:

• A random-effects model had been adopted;

• The summary effect measure was risk ratio rather than odds ratio.

Overall quality of the body of evidence: 'Summary of findings' table

We prepared a 'Summary of findings' table using GRADEpro Guideline Development Tool

(GRADEpro GDT 2015). This table evaluated the overall quality of the body of evidence for

all review outcomes (live birth, OHSS, ongoing pregnancy, clinical pregnancy, miscarriage

and cycle cancellation), using GRADE criteria (study limitations (i.e. risk of bias), consistency

of effect, imprecision, indirectness and publication bias). Judgments about evidence quality

(high, unclear (moderate) or low) were justified, documented, and incorporated into reporting

of results for each outcome

30

Results

Description of studies

Results of the search

Results of the search: We retrieved 479 records after removal of duplicates, excluded 399

as ineligible, and assessed 80 full-text articles. Of these, we excluded 51 and included 28

studies (29 reports). Seventy-three randomised controlled studies (84 reports), involving

12,212 randomised women, met the inclusion criteria and were fully reviewed (See Figure 1

for details of this process).

Included studies

Study characteristics: Twelve studies were multi-centre (Albano 2000; Baart 2007; Barmat

2005; Euro Middle East 2001; Euro Orgalutran 2000; Fluker 2001; Heijnen 2007; Huirne

2006; Olivennes 2000; Qiao 2012; Rombauts 2006; Sauer 2004), 43 studies were single-

centre trials, while in the remaining studies it was unclear whether they were multi-centre or

single centre.

We considered sample size calculations to be appropriate when the authors of the studies

pre-calculated the number needed in each arm prior to starting the trial. This helps to prevent

the occurrence of type II errors. Fifteen studies reported that they had performed a priori

sample size calculations (Hwang 2004; Baart 2007; Cota 2012; Engmann 2008a; Heijnen

2007; Huirne 2006; Kim 2011; Kurzawa 2008; Lainas 2010; Sbracia 2009; Sunkara 2014;

Tehraninejad 2010; Lin 2006; Depalo 2009; Tazegul 2008); 22 studies reported that they had

not performed a sample size calculation; and it was not clear if sample size calculations had

been performed in the remaining 36 studies.

Twenty-three studies said that they had performed intention-to-treat analysis (Badrawi 2005;

Choi 2012; Cota 2012; Depalo 2009; Engmann 2008a; Euro Middle East 2001; Euro

Orgalutran 2000; Fluker 2001; Heijnen 2007; Hosseini 2010; Huirne 2006; Hwang 2004;

Khalaf 2010; Kim 2004; Kim 2011; Lin 2006; Loutradis 2004; Marci 2005; Rombauts 2006;

Sauer 2004; Serafini 2008; Sunkara 2014; Xavier 2005); 16 studies reported that the original

analyses did not use the intention-to-treat principle (Albano 2000; Baart 2007; Bahceci 2005;

Cheung 2005; El Sahwi 2005; Firouzabadi 2010; Hohmann 2003; Inza 2004; Kurzawa 2008;

Kyono 2005; Lee 2005; Olivennes 2000; Sbracia 2009; Tazegul 2008; Tehraninejad 2010;

Ye 2009); it was not reported clearly in the rest of the studies.

31

Figure.1 PRISMA study flow diagram

32

Participants: Seventy out of 73 studies reported that baseline characteristics were

comparable between groups (Characteristics of included studies table) and three did not

report information on this. In eighteen of the studies, age was the only reported characteristic

compared. Of the 73 included studies, 49 trials involved an unspecified population of infertile

couples, while the remaining trials were performed in specific infertile populations. These

populations were or included 'poor responders' (Al-Karaki 2011; Cheung 2005; Inza 2004;

Kim 2011; Kim 2012; Marci 2005; Mohamed 2006; Prapas 2013; Revelli 2014; Sbracia 2009;

Sunkara 2014; Tazegul 2008; Toltager 2015) or had polycystic ovary syndrome (Bahceci

2005; Choi 2012; Engmann 2008a; Haydardedeoglu 2012; Hosseini 2010; Hwang 2004; Kim

2004; Kurzawa 2008; Lainas 2007; Lainas 2010; Moshin 2007; Tehraninejad 2010). The

number of randomised women ranged from 20 (Franco 2003) to 1099 (Toltager 2015),

including both the GnRH agonist and antagonist groups.

Fifteen studies included 300 or more participants (Awata 2010; Euro Middle East 2001; Euro

Orgalutran 2000; Tehraninejad 2011; Gizzo 2014; Haydardedeoglu 2012; Heijnen 2007;

Martinez 2008; Prapas 2013; Revelli 2014; Rinaldi 2014; Rombauts 2006; Sbracia 2009;

Toltager 2015). There were 30 studies with fewer than 100 participants (Anderson 2014;

Barmat 2005; Celik 2011; Check 2004; Cheung 2005; Choi 2012; Cota 2012; Engmann

2008a; Ferrari 2006; Franco 2003; Friedler 2003; Hershko Klement 2015; Hoseini 2014;

Hwang 2004; Inza 2004; Khalaf 2010; Kim 2004; Kurzawa 2008; Lainas 2007; Lavorato

2012; Lee 2005; Marci 2005; Mohamed 2006; Moraloglu 2008; Moshin 2007; Sauer 2004;

Serafini 2008; Stenbaek 2015 Tazegul 2008; Tehraninejad 2010). Five studies were

published before 2002. There were 28 studies published between 2002 and 2006, 18 studies

published between 2007 and 2010 and 23 studies between 2011 and 2015

Intervention: All included studies compared GnRH antagonist with long-course GnRH

agonist protocols in women undergoing IVF or ICSI cycles. We identified three types of

antagonist protocols: (1) single, long-acting administration (Hsieh 2008; Lee 2005; Moshin

2007; Olivennes 2000); (2) fixed, daily administration (Albano 2000; Cheung 2005; Euro

Middle East 2001; Euro Orgalutran 2000; Firouzabadi 2010; Fluker 2001; Haydardedeoglu

2012; Hoseini 2014; Hsieh 2008; Huirne 2006; Hwang 2004; Martinez 2008; Moshin 2007;

Sauer 2004); and (3) flexible daily administration (Baart 2007; Badrawi 2005; Bahceci 2005;

Barmat 2005; Brelik 2004; Check 2004; Choi 2012; Depalo 2009; El Sahwi 2005; Engmann

2008a; Franco 2003; Hershko Klement 2015; Hohmann 2003; Karimzadeh 2010; Kim 2004;

Kim 2011; Kurzawa 2008; Lainas 2007; Lainas 2010; Lee 2005; Lin 2006; Loutradis 2004;

Marci 2005; Moraloglu 2008; Rombauts 2006; Sbracia 2009; Serafini 2008; Tazegul 2008;

Tehraninejad 2010; Xavier 2005; Ye 2009). In the fixed daily protocol, in most of the studies,

33

GnRH antagonist was begun on day six of FSH treatment regardless of follicle size. In the

flexible daily protocol, GnRH antagonist was administered according to the lead follicle size

and not the cycle date, nor the day of FSH administration. In 25 of the included studies, the

type of antagonist protocol used was not reported.

In 44 included trials, the antagonist cetrorelix was administered (Albano 2000; Al-Karaki

2011; Bahceci 2005; Brelik 2004; Cheung 2005; Cota 2012; Depalo 2009; El Sahwi 2005;

Ferrari 2006; Ferrero 2010; Hershko Klement 2015; Hohmann 2003; Hoseini 2014; Hosseini

2010; Hsieh 2008; Huirne 2006; Hwang 2004; Khalaf 2010; Kim 2004; Kim 2011; Kim 2012;

Kurzawa 2008; Kyono 2005; Lainas 2010; Lavorato 2012; Lee 2005; Lin 2006; Loutradis

2004; Marci 2005; Mohamed 2006; Moraloglu 2008; Moshin 2007; Olivennes 2000; Rabati

2012; Revelli 2014; Rinaldi 2014; Sauer 2004; Sbracia 2009; Serafini 2008; Sunkara 2014;

Tehraninejad 2010; Tehraninejad 2011; Xavier 2005; Ye 2009). In 19 trials, the antagonist

ganirelix was administered (Baart 2007; Badrawi 2005; Barmat 2005; Check 2004; Engmann

2008a; Euro Middle East 2001; Euro Orgalutran 2000; Firouzabadi 2010; Fluker 2001;

Franco 2003; Gizzo 2014; Haydardedeoglu 2012; Karimzadeh 2010; Lainas 2007; Martinez

2008; Prapas 2013; Qiao 2012; Rombauts 2006; Stenbaek 2015). Three trials used both

cetrorelix and ganirelix (Choi 2012; Papanikolaou 2012; Tazegul 2008) and in seven included

trials the type of antagonist used was unclear (Anderson 2014; Awata 2010; Celik 2011;

Friedler 2003; Heijnen 2007; Inza 2004; Toltager 2015).

Oral contraceptive pill pre-treatment was used in 18 studies (Barmat 2005; Cheung 2005;

Engmann 2008a; Haydardedeoglu 2012; Hershko Klement 2015; Hosseini 2010; Huirne

2006; Kim 2004; Kim 2011; Kim 2012; Kurzawa 2008; Kyono 2005; Lainas 2007; Lainas

2010; Moraloglu 2008; Rombauts 2006; Sauer 2004; Tehraninejad 2010). Further single

trials used Diane (Hwang 2004), estradiol in the luteal phase (Franco 2003), and vaginal

Nuvaring (Martinez 2008).

Women randomised to treatment with GnRH antagonist started ovarian stimulation on day

two to three of the menstrual cycle. The GnRH antagonist was started on stimulation day six,

by daily subcutaneous administration up to and including the day of human chorionic

gonadotrophin (hCG) administration in the fixed protocol or depending on the dominant

follicle size in the flexible protocol. The GnRH long agonist reference treatment was started

in the mid-luteal phase (cycle day 21 to 24) by either daily intranasal or subcutaneous

administration.

Ovarian stimulation was started after two weeks if pituitary down-regulation was established

(serum estradiol level < 50 pg/ml). In both treatment groups, ovarian stimulation was started

34

with a fixed daily dose of 150 IU or 225 IU recombinant follicle stimulating hormone (rFSH) or

human menopausal gonadotrophin (hMG) for the first five stimulation days. Thereafter, the

dose of FSH was adapted depending on the ovarian response, as monitored via

ultrasonography (US). Triggering of ovulation was induced with hCG (10,000 IU) if at least

three follicles that were more than 17 mm in diameter were observed by US.

Trigger used: the majority of the included studies used hCG trigger or did not state which

trigger was used; one of the included studies used a combination of both hCG and GnRH

agonist as trigger agents (Engmann 2008a).

Outcomes; Study participant follow up: the optimum follow up would be to report on the

number of single, healthy babies going home with their parents (for example single, live,

take-home baby rate). If unavailable, other follow ups were assessed including the live birth

rate (LBR) and ongoing pregnancy rate (OPR). None of the included trials described the

single, live, take-home baby rate or the take-home baby rate. Twelve studies reported on the

LBR (Albano 2000; Baart 2007; Barmat 2005; Heijnen 2007; Kim 2011; Kim 2012; Kurzawa

2008; Lin 2006; Marci 2005; Papanikolaou 2012; Rinaldi 2014; Ye 2009). Further, 36 trials

reported the OPR and 55 studies reported the clinical pregnancy rate (CPR).

Thirty-six studies reported OHSS incidence (Albano 2000; Badrawi 2005; Bahceci 2005;

Barmat 2005; Engmann 2008a; Euro Middle East 2001; Euro Orgalutran 2000; Firouzabadi

2010; Fluker 2001; Haydardedeoglu 2012; Heijnen 2007; Hohmann 2003; Hosseini 2010;

Hsieh 2008; Huirne 2006; Hwang 2004; Karimzadeh 2010; Kim 2012; Kurzawa 2008; Kyono

2005; Lainas 2007; Lainas 2010; Lee 2005; Lin 2006; Moraloglu 2008; Moshin 2007;

Olivennes 2000; Papanikolaou 2012; Qiao 2012; Rabati 2012; Rombauts 2006; Serafini

2008; Tehraninejad 2010; Toltager 2015; Xavier 2005; Ye 2009).

Ten studies did not present data in a form that could be included in meta-analysis (Anderson

2014; Awata 2010; Celik 2011; Choi 2012; Cota 2012; Ferrero 2010; Hoseini 2014; Khalaf

2010; Lavorato 2012; Stenbaek 2015).

Excluded studies: Forty seven studies were excluded for various reasons

Risk of bias in included studies

Allocation (selection bias): Randomisation was done at the time of recruitment of

participants. All trials had a parallel design and proper randomisation was carried out by 39

studies by using: interactive voice response systems (Albano 2000; Euro Middle East 2001;

Euro Orgalutran 2000; Rombauts 2006); stratified randomisation (Fluker 2001); computer-

35

generated random number tables with or without sealed envelopes for allocation

concealment (Baart 2007; Badrawi 2005; Barmat 2005; Cota 2012; Depalo 2009; Engmann

2008a; Ferrari 2006; Firouzabadi 2010; Franco 2003; Tehraninejad 2011; Heijnen 2007;

Hohmann 2003; Huirne 2006; Hwang 2004; Karimzadeh 2010; Kim 2011; Kim 2012;

Kurzawa 2008; Lainas 2007; Lainas 2010; Lavorato 2012; Loutradis 2004; Martinez 2008;

Moraloglu 2008; Papanikolaou 2012; Rinaldi 2014; Sauer 2004; Sbracia 2009; Tazegul 2008;

Tehraninejad 2010; Ye 2009; Xavier 2005); or random number table (Bahceci 2005; Cheung

2005; Haydardedeoglu 2012).

Allocation concealment was properly performed by a nurse (Cota 2012; Lainas 2007;

Papanikolaou 2012), by an interactive telephone system (Martinez 2008) or by a sealed

opaque envelope (Haydardedeoglu 2012; Hershko Klement 2015; Prapas 2013; Revelli

2014; Rinaldi 2014).The remaining trials did not report the methods of sequence generation

or allocation concealment, or both.

Blinding (performance bias and detection bias): We examined blinding with regard to who

was blinded in the trials. We looked for all levels of blinding and categorised them as follows:

(i) double blind (neither the investigator nor the participants knew the allocation); (ii) single

blind (only the investigator knew the allocation); (iii) no blinding (both the investigator and the

participants knew the allocated treatment); (iv) unclear.

Since it was impossible to administer the different medications (that is long agonist and

antagonist) according to one standard protocol without the use of a double dummy, almost all

the studies were open-label (that is no blinding). One study (Cheung 2005) blinded the

clinicians and embryologists from the treatment allocation by using a nurse practitioner to

administer the medications. The embryologist scoring the embryos, or the researcher, was

blinded to the study groups in five trials (Baart 2007; Depalo 2009; El Sahwi 2005; Hwang

2004; Martinez 2008).

Twenty-seven trials reported no blinding and we assessed them as being at high risk of bias

(Albano 2000; Badrawi 2005; Bahceci 2005; Barmat 2005; Check 2004; Engmann 2008a;

Euro Middle East 2001; Euro Orgalutran 2000; Firouzabadi 2010; Fluker 2001; Franco 2003;

Friedler 2003; Heijnen 2007; Hohmann 2003; Kurzawa 2008; Kyono 2005; Lainas 2007;

Lainas 2010; Loutradis 2004; Marci 2005; Olivennes 2000; Rombauts 2006; Sauer 2004;

Tazegul 2008; Tehraninejad 2010; Xavier 2005; Ye 2009). The remaining trials did not

clearly report if blinding was performed and we therefore assessed them as being at unclear

risk of bias. However, some of the outcome measures such as live birth were objectively

36

assessed and non-blinding of study outcome assessors was not likely to have affected their

measurement.

Incomplete outcome data (attrition bias): We judged thirty-seven of the included studies

as being at low risk of bias in this domain, because they reported that there were no losses

to follow up, proportions of withdrawals and reasons for withdrawals were balanced in both

treatment groups, or women were analysed on the basis of intention-to-treat, where all

women randomised were included in the final analysis whether or not they completed

treatment. We judged the remaining studies either as unclear (where studies reported

insufficient information with regard to attrition) or high risk of bias (where proportions of and

reasons for withdrawals were not balanced between the two treatment groups and not all

participants were included in the final analysis).

Selective reporting (reporting bias): Although the protocols of the included studies were

not available for assessment, we scrutinised the methods section for pre-specified outcome

measures. Most of the included studies were rated as low risk of bias in this domain as they

pre-specified the outcomes on which data were reported in the methods section. The

remaining studies were judged to be either at unclear risk, where there was insufficient

information to make conclusive judgments, or low risk, where it was clear that they engaged

in selective outcome reporting.

Other potential sources of bias: We found no potential sources of within-study bias in most

of the included studies as the baseline characteristics were similar between the treatment

groups and were, therefore, rated to be at low risk of bias. The remaining studies were rated

either as unclear risk, where there was insufficient information to arrive at a judgment, or high

risk where there was evidence of significant differences in demographic characteristics

between the treatment groups.

Effects of interventions: The included studies enrolled a total of 12,212 randomised

participants, although the sample size varied across the trials. We performed the analyses on

the number of women randomised and not on the number of participants treated.

GnRH antagonist versus long course GnRH agonist

Primary outcomes

1.1 Live birth rate per woman randomised: Twelve trials reported live birth rates in 2303

women. There was no evidence of a difference following GnRH antagonist compared with

GnRH agonist (OR 1.02, 95% CI 0.85 to 1.23; I2 = 27%, moderate quality evidence). The

37

evidence suggested that if the chance of live birth following treatment with GnRH agonist is

assumed to be 29%, the chance following treatment with GnRH antagonist would be

between 25% and 33%. On sensitivity analysis, there was no change in the above

conclusion using a random-effects model (OR 1.01, 95% CI 0.80 to 1.27) or using risk ratio

(RR) as a measure of effect estimate (RR 1.02, 95% CI 0.89 to 1.15). A funnel plot to explore

the possibility of small study effect showed a tendency for estimates of the intervention effect

to be more beneficial in smaller studies in the GnRH antagonist group

1.2 Live birth rate per woman randomised - Subgroup analysis: Minimal stimulation

Two trials reported live birth rates in 524 women undergoing minimal stimulation IVF. There

was no evidence of a difference following GnRH antagonist treatment compared with GnRH

agonist treatment (OR 0.89, 95% CI 0.62 to 1.26; I2 = 0%).

1.3 Live birth rate per woman randomised - Subgroup analysis: Grouped by trigger

1.3.1 hCG trigger; In a subgroup analysis, 11 trials reported live birth rates in 1899 women

receiving hCG for ovarian maturation. There was no evidence of a difference following GnRH

antagonist treatment compared with GnRH agonist treatment (OR 1.09, 95% CI 0.89 to 1.34;

I2 = 26%).

1.3.2 Unknown trigger: One trial did not report the triggering agent used for ovarian

maturation in 404 women. There was no evidence of a difference in live birth rate between

GnRH antagonist and GnRH agonist treatment groups (OR 0.80, 95% CI 0.54 to 1.21).

1.4 Ovarian hyperstimulation per woman randomised: Thirty-six trials reported ovarian

hyperstimulation rates in 7944 women. There was evidence of a lower OHSS rate in women

who received GnRH antagonist compared with those were treated with GnRH agonist:

290/4474 (6%) versus 396/3470 (11%) (OR 0.61, 95% CI 0.51 to 0.72; I2 = 31%, moderate

quality evidence). The evidence suggested that if the risk of OHSS following GnRH agonist is


1.5 Ovarian hyperstimulation per woman randomised - Subgroup analysis: Moderate or severe OHSS: Twenty trials reported moderate or severe ovarian hyperstimulation rates

in 5141 women. There was evidence of a lower rate of moderate or severe OHSS in GnRH

antagonist compared with GnRH agonist groups: 97/2971 (3%) versus 155/2170 (7%) (OR

0.53, 95% CI 0.40 to 0.69; I2 = 17%).

38

Figu

re 2

:For

est p

lot f

or li

ve b

irth

rate

per

wom

an ra

ndom

ised

39

Figure 3: Forest plot for OHSS incidence per woman randomoised

40

Secondary outcomes

1.6 Ongoing pregnancy rate per woman randomised: Thirty-seven trials reported ongoing

pregnancy rates in 8311 women. There was no evidence of a difference in ongoing

pregnancy rate following treatment with GnRH antagonist compared with GnRH agonist (OR

0.92, 95% CI 0.83 to 1.01; I2 = 0%; moderate quality evidence). The evidence suggested that

if the chance of ongoing pregnancy following GnRH agonist treatment is assumed to be 29%,

the chance following GnRH antagonist treatment would be between 26% and 30%. There

was no change in the conclusion on sensitivity analysis using either a random-effects model

(OR 0.91, 95% CI 0.83 to 1.01) or RR as a measure of treatment effect (RR 0.94, 95% CI

0.88 to 1.01).

1.7 Ongoing pregnancy rate per woman randomised - Subgroup analysis: Minimal stimulation: Seven trials reported ongoing pregnancy rates in 1456 women undergoing

minimal stimulation IVF. There was no evidence of a difference following GnRH antagonist

treatment compared with GnRH agonist treatment (OR 0.94, 95% CI 0.75 to 1.18; I2 = 0%).

1.8 Ongoing pregnancy rate per woman randomised - Subgroup analysis: Grouped by trigger

1.8.1 hCG trigger: In a subgroup analysis, 29 studies reported ongoing pregnancy rate in

5170 women in whom hCG was used to trigger oocyte maturation. There was no evidence of

a difference in ongoing pregnancy rate between the two treatment groups (OR 0.95, 95% CI

0.84 to 1.08; I2 = 0%).

1.8.2 Mixed trigger: One study used hCG and GnRH agonist in GnRH antagonist and

GnRH agonist groups respectively to trigger oocyte maturation in 66 women. There was no

evidence of a difference in ongoing pregnancy rate between GnRH antagonist and GnRH

agonist groups (OR 0.61, 95% CI 0.23 to 1.61).

1.8.3 Unknown trigger: In a subgroup analysis, seven trials reported ongoing pregnancy

rates in 3075 women in whom the agent used in triggering oocyte maturation was unknown.

There was no evidence of a difference following treatment with GnRH antagonist compared

with GnRH agonist (OR 0.87, 95% CI 0.74 to 1.03; I2 = 0%).

1.9 Clinical pregnancy rate per woman randomised: Fifty-four trials reported clinical

pregnancy rates in 9959 women. There was evidence of a difference following GnRH

antagonist treatment compared with GnRH agonist treatment with a smaller proportion of

women reporting clinical pregnancies in the GnRH antagonist group: 1510/5431 (28%)

41

versus 1365/4528 (30%) (OR 0.91, 95% CI 0.83 to 1.00; I2 = 1%, moderate quality

evidence). The evidence suggested that if the chance of clinical pregnancy following GnRH

agonist treatment is assumed to be 30%, the chance following GnRH antagonist treatment

would be between 27% and 30%.

1.10 Clinical pregnancy rate per woman randomised - Subgroup analysis: Minimal stimulation

Six studies reported clinical pregnancy rate in 1102 women receiving minimal ovarian

stimulation. There was evidence of a higher clinical pregnancy rate in the GnRH antagonist

group compared to the GnRH agonist group: 179/552 (32%) versus 137/550 (25%) (OR

1.50, 95% CI 1.15 to 1.96; I2 = 50%).

1.11 Miscarriage rate per woman randomised: Thirty-four trials reported miscarriage rates

in 7082 women. There was no evidence of a difference following GnRH antagonist treatment

compared with GnRH agonist treatment (OR 1.03, 95% CI 0.82 to 1.29; I2 = 0%; moderate

quality evidence). The evidence suggested that if the risk of miscarriage following GnRH

agonist treatment is assumed to be 5%, the risk following GnRH antagonist treatment would

be between 4% and 6%.

1.12 Miscarriage rate per clinical pregnancy rate: Thirty-four trials reported miscarriage

rates per clinical pregnancy rates in 2308 women. There was no evidence of a difference

following treatment with GnRH antagonist compared with GnRH agonist (OR 1.08, 95% CI

0.84 to 1.37; I2 = 0%).

1.13 Cycle cancellation rate per woman randomised

1.13.1 Cancelled due to high risk of OHSS: Nineteen trials reported rates of cycle

cancellation due to high risk of OHSS in 4256 women. There was evidence of a difference in

cancellation rates with fewer cycles cancelled in the GnRH antagonist groups compared with

the GnRH agonist groups (OR 0.47, 95% CI 0.32 to 0.69; I2 = 0%).

1.13.2 Cancellation due to poor ovarian response: Twenty-five trials reported rates of

cancellation due to poor ovarian response in 5230 women. There was evidence of a

difference in cycle cancellation rates with more cycles cancelled in GnRH antagonist groups

compared with GnRH agonist groups (OR 1.32, 95% CI 1.06 to 1.65; I2 = 68%, moderate

quality evidence). The evidence suggested that if the risk of cycle cancellation following

GnRH agonist treatment is assumed to be 6%, the risk following GnRH antagonist treatment

would be between 7% and 10%. There was evidence of statistical heterogeneity among the

42

trials that contributed data to the pooled effect estimate, with variations in the direction of

effect estimates of individual trials. On sensitivity analysis using a random-effects model,

there was no evidence of a difference in cancellation rate between the two treatment groups

(OR 1.38, 95% CI 0.82 to 2.31). Thus there is some degree of uncertainty with respect to this

outcome, as it is sensitive to the choice of statistical model.

Discussion

The previous version of this systematic review included 45 studies, while this updated

version includes 73 RCTs and 12,212 randomised women. To our knowledge this systematic

review and meta-analysis represents the most recent and largest amount of evidence

comparing the use of GnRH antagonist with long-course GnRH agonist protocols in IVF or

ICSI treatment cycles.

In this updated version of the review we focused on the effectiveness and safety of GnRH

antagonist compared to GnRH agonist cycles in ART. Regarding effectiveness, there was

no evidence of differences in live birth rate and ongoing pregnancy rate between GnRH

agonist and GnRH antagonist LH peak suppression protocols.

With regard to safety, GnRH antagonists substantially reduced the incidence of OHSS. For

the overall population from assembled studies, the evidence suggested that, if the risk of

OHSS following GnRH agonist is assumed to be 11%, the risk following GnRH antagonist

would be between 6% and 9%. In addition, there was evidence of a lower rate of moderate or

severe OHSS in women who received the GnRH antagonist protocol compared with those

who were treated with the GnRH agonist long protocol. However there was no evidence of a

difference in miscarriage rates per woman randomised between the two treatment protocols.

There was no clear picture with respect to cycle cancellation between the two treatment

groups. While fewer cycles were cancelled in the GnRH antagonist group due to high risk of

OHSS, there is some degree of uncertainty with cancellation due to poor ovarian response,

as this outcome was sensitive to the choice of statistical model. In summary, there is

moderate quality evidence that the use of GnRH antagonist compared with long-course

GnRH agonist protocols is associated with a substantial reduction in OHSS without reducing

the likelihood of achieving live birth or ongoing pregnancy.

Previous versions of this systematic review showed substantially lower clinical and ongoing

pregnancy rates for the GnRH antagonist protocol. Two earlier meta-analyses of studies,

comparing fixed and flexible GnRH antagonist protocols directly, demonstrated a trend

towards higher pregnancy rates when using the fixed protocol, possibly explained by better

43

LH control (Al-Inany 2005; Kolibianakis 2006). The improved performance of antagonist

cycles in the present update cannot be explained by the relative use of fixed protocols

however, as relatively few new fixed protocols were included.

Several studies have suggested that LH instability decreases the probability of pregnancy in

antagonist cycles (Bosch 2003; Kolibianakis 2003; Seow 2010; Shoham 2002). LH instability

is defined as any fluctuation in LH level, either a LH surge or rise in LH concentration, in the

course of ovarian hyperstimulation. A decrease in the relative incidence of LH instability in

the current review can possibly have improved pregnancy outcomes in antagonist cycles,

although the mechanism for such change is still unclear. Further studies are needed to

investigate the possible role of LH-instability in the improvement of pregnancy outcomes of

GnRH antagonist cycles.

Increased favorable pregnancy outcomes with GnRH antagonist treatment may also be the

result of an improved learning curve with the relatively new GnRH antagonist over the last 15

years. Extensive experience with GnRH antagonist protocols in large studies, leading to

more favorable study outcomes, may have positively influenced pregnancy outcomes of

GnRH antagonist cycles. Finally, changes in the use of OCP pretreatment (Griesinger 2008),

scheduling of hCG for final oocyte maturation (Kolibianakis 2004; Tremellen 2010; Orvieto

2008) or patient selection (Sbracia 2009) may all have contributed to the optimisation of the

use of antagonist cycles in ART. However, the improvement in pregnancy outcomes could

also be due to the effects of potential bias in the included studies. For example, the forest

plot suggests a tendency for publication of studies with more favorable outcomes with the

possibility of existence of unpublished studies with less favorable outcomes.

Previous work on the role of OCP pretreatment in direct comparison studies has indicated

that OCP pretreatment leads to a longer duration of stimulation, higher oocyte yield, but

reduced ongoing pregnancy rate (Smulders 2010). Also a trend towards lower pregnancy

rates when using OCP pretreatment has been observed in a separate meta-analysis

(Griesinger 2008). As such, it has been recommended that OCP pretreatment does not seem

to be the regimen of choice for GnRH antagonist cycles. In the previous versions of this

review, however, a subgroup analysis of studies that used OCP pretreatment revealed no

substantial difference between the agonist and antagonist groups for ongoing or clinical

pregnancy rates. The percentage of women receiving OCP pretreatment in the 2011 update

was comparable with the preceding version in 2006.

44

Overall, the data demonstrate that GnRH antagonist is useful in women undergoing IVF or

ICSI because it substantially reduces the occurrence of OHSS without reducing the chances

of achieving live a live birth.

A long-course GnRH agonist protocol with maximum ovarian stimulation has been the

standard protocol for many decades. However, it is relatively complex and expensive,

requires long treatment cycles and intensive monitoring, and leads to an abnormal hormonal

environment in women. There is now an eager desire to shift to more patient-friendly, mild

ovarian-stimulation regimens in which GnRH antagonist may be a suitable solution because

there is evidence to suggest that its use is associated with comparable pregnancy outcomes.

A good number of the included studies did not report live birth and OHSS: 12 of the included

studies reported data on live birth while only 36 reported data on OHSS. One study used

single embryo transfer in the antagonist arm and double embryo transfer in the agonist arm.

Some of the outcomes of interest were reported by some of the included studies in such a

way that they could not be included in meta-analyses. For example, some of the

denominators were reported as 'per oocyte' or 'per embryo' transferred, where the numbers

of oocytes or embryos transferred were not equal to the number of women randomised. In

some of the included studies, some outcomes were not properly defined making it difficult to

categorise such outcomes, for example, 'pregnancy rate' which could either be 'ongoing' or

'clinical' pregnancy. We included a small number of studies because they met the inclusion

criteria, although they did not report data on any of the outcomes of interest. With respect to

the triggering agent used for oocyte maturation, the majority of the studies either used hCG

or did not report the triggering agent used. Thus no comparison could be made between the

triggering agents such as hCG versus GnRH agonist.

The evidence was of moderate quality using GRADE ratings for live birth, OHSS, ongoing

pregnancy, clinical pregnancy, miscarriage and cycle cancellation due to poor ovarian

response. The main limitations in the evidence were poor reporting of study methods. For

example, a majority of the included studies either did not report the processes involved in

random sequence generation and allocation concealment or reported vague and insufficient

information on the processes, thereby making it difficult to make conclusive judgments on

these domains of risk of bias. Poor reporting also affected the assessment of other domains

of risk of bias with most of them being rated as 'unclear'. For live birth, there was evidence

suggestive of the possibility of reporting (publication) bias with small studies more likely to

report favorable outcomes for GnRH antagonist.

45

Although comprehensive searches were undertaken to ensure that all eligible studies were

identified, it is not impossible that some potentially eligible studies could have been left out.

A systematic review and meta-analysis, Youssef 2012, compared the effectiveness and

safety of various protocols including GnRH antagonist versus long-course GnRH agonist

protocol. There was no evidence of a difference between women who received GnRH

antagonist and those who were treated with long-course GnRH agonist protocol in three

RCTs, either in clinical pregnancy rate (OR 0.72, 95% CI 0.49 to 1.05, five RCTs) or cycle

cancellation rate (OR 1.25, 95% CI 0.76 to 2.05).

There is a systematic review and meta-analysis that included 22 RCTs (n = 3176) to

compare GnRH antagonists and GnRH agonists (Kolibianakis 2006). The reported outcome

measure, clinical pregnancy or ongoing pregnancy, was converted to live births in 12 studies

using the published data. No evidence of a difference was detected in the probability of a live

birth between the two GnRH analogues (OR 0.86, 95% CI 0.72 to 1.02). The result remained

stable in a subgroup analysis that ordered the studies by type of population studied,

gonadotrophin type used for stimulation, type of agonist protocol used, type of agonist used,

type of antagonist protocol used, type of antagonist used, presence of allocation

concealment, presence of co-intervention and the way the information on live births was

retrieved.

A systematic review and meta-analysis, Franco 2006, evaluated the efficacy of

gonadotrophin antagonist versus GnRH agonist in poor ovarian responders in IVF and ICSI

cycles. The review included six RCTs that compared GnRH antagonist to long or short GnRH

agonist. There was no difference between GnRH antagonist and GnRH agonist (long and

flare-up protocols) with respect to cycle cancellation rate, number of mature oocytes and

clinical pregnancy rate per cycle initiated, per oocyte retrieval and per embryo transfer. When

the meta-analysis was applied to the two trials that had used GnRH antagonist versus long

protocols of GnRH agonist, a significantly higher number of retrieved oocytes was observed

in the GnRH antagonist protocols (MD 1.12, 95% CI 0.18 to 2.05; P = 0.018).

In another systematic review and meta-analysis of four RCTs (n = 874) ongoing pregnancy

rate was the main outcome (Griesinger 2008). There was no evidence of a statistically

significant difference between women with and without OCP pre-treatment (OR 0.74, 95% CI

0.53 to 1.03). Duration of gonadotrophin stimulation (1.41 days, 95% CI 1.13 to 1.68) and

gonadotrophin consumption (542 IU, 95% CI 127 to 956) were significantly increased after

OCP pre-treatment. No significant differences were observed regarding the number of

retrieved oocytes.

46


Implications for practice: The GnRH antagonist protocol is a short and simple protocol with

evidence suggesting a comparable live birth rate and a substantial reduction in the incidence

of ovarian hyperstimulation syndrome when compared to GnRH agonist long protocol in

women undergoing ART.

Implications for research: In view of the shortcomings noted in the included studies,

especially with regard to the methods of reporting of trial procedures, more properly designed

studies in accordance with the CONSORT statement are need to further evaluate the

effectiveness and safety of the GnRH antagonist protocol (Schulz 2010). For example, it

would be desirable to have trials with low risk of bias with primary outcomes of live birth and

OHSS. In addition, further studies are needed to assess this treatment regimen in poor and

high responders. We attempted to subgroup treatment regimens by the ovulation triggering

agent but no data were available for a proper analysis, as the majority of the included studies

either used hCG or did not specify their triggering agents. This is a potential area to be

explored by future research. It is also important to understand why pregnancy outcomes

have become progressively more favorable with the use of GnRH antagonists. One possible

explanation for this could be a decrease in LH instability. This area should be further

investigated. Although not a focus of the current update, the potential effects of OCP

pretreatment should be further investigated.

Patient satisfaction surveys should also be undertaken to evaluate their impression about

GnRH antagonist treatment regimens.

Acknowledgements

The authors would like to thank all members of the Gynaecology and Fertility Group for their

valuable support in this review. The authors also wish to acknowledge the following people

for their contributions to the previous versions of the review: Monique D. Sterrenburg, Janine

G Smit, Ahmed M Abou-Setta, and Mohamed Aboulghar.

47

References

Included studies • Albano C, Felberbaum R, Smitz J, Riethmuller-Winzen H, Engel J, Diedrich K, et al.

Ovarian stimulation with HMG: results of a prospective randomized phase III European study comparing the luteinizing hormone-releasing hormone (LHRH)-antagonist cetrorelix and the LHRH-agonist buserlin. Human Reproduction 2000;15(3):526-31.

• Ludwig M, Felberbaum RE, Devroey P, Albano C, Riethmuller-Winzen H, Schuler A, et al. Significant reduction of the incidence of ovarian hyperstimulation syndrome (OHSS) by using the LHRH antagonist cetrorelix (Cetrotide) in controlled ovarian stimulation for assisted reproduction. Archives of Gynecology and Obstetrics 2000;264(1):29-32.

• Al-Karaki R, Irzouqi R, Khalifa F, Taher M, Sarraf M. Effectiveness of flexible GnRH antagonist protocol versus minidose long GnRH agonist protocol in poor-responder patients undergoing IVF. Human Reproduction 2011; 26(1):i47.

• Anderson S, Pereira NE, Brasile DR, Orris JJ, Davies EB, Glassner MJ. Comparison of antagonist to agonist in controlled ovarian stimulation (COS) cycles using human-derived gonadotropin on in vitro fertilization (IVF) outcomes. A prospective randomized controlled study. In: Fertility and sterility. Vol. 102 (3; Suppl 1). 2014:e224.

• Awata S, Tanaka A, Nagayoshi M. Selection of an optimal controlled ovarian hyperstimulation method in relation to the number of antral follicles in patients less than 40 years old. Fertility and Sterility 2010; 94 suppl 1(4):S164 Abstract no. P-244.

• Baart EB, Martini E, Eijkemans MJ, Van Opstal D, Beckers NGM, Verhoeff A, et al. Milder ovarian stimulation for in-vitro fertilization reduces aneuploidy in the human preimplantation embryo: a randomized controlled trial. Human Reproduction 2007;22(4):980-8.

• Badrawi A, Al-Inany H, Hussein M, Zaki S, Ramzy AM. Agonist versus antagonist in ICSI cycles: a randomized trial and cost effectiveness analysis. Middle East Fertility Society Journal 2005; 10(1):49-54.

• Bahceci M, Ulug U, Ben-Shlomo I, Erden HF, Akman MA. Use of a GnRH antagonist in controlled ovarian hyperstimulation for assisted conception in women with polycystic ovary disease: a randomized, prospective, pilot study. Journal of Reproductive Medicine 2005; 50(2):84-90.

• Barmat LI, Chantilis SJ, Hurst BS, Dickey RP. A randomized prospective trial comparing gonadotropin-releasing hormone (GnRH) antagonist/recombinant follicle-stimulating hormone (r FSH) versus GnRH-agonist/r FSH in women pretreated with oral contraceptives before in vitro fertilization. Fertility and Sterility 2005; 83(2):321-30.

48

• Brelik P, Kurzawa R, Baczkowski T, Sienkiewicz R, Glabowski W. Assessment of the predictive value of LH levels in IVF cycles stimulated with GnRH antagonists and agonists. Human Reproduction 2004; 19:i62.

• Celik N, Celik O, Aktan E, Ozerol E, Celik E, Bozkurt K, et al. Plasma urocortin levels in women undergoing long agonist and antagonist protocols for IVF. Human Reproduction 2011; 26(1):i203.

• Check ML, Check JH, Choel JK, Davies E, Kiefer D. Effect of antagonists vs. agonists on in vitro fertilization outcome. Clinical and Experimental Obstetrics & Gynecology 2004; 31(4):257-9.

• Cheung LP, Lam PM, Lok IH, Chiu TT, Yeung SY, Tjer CC, et al. GnRH antagonist versus long GnRH agonist protocol in poor responders undergoing IVF: a randomized controlled trial. Human Reproduction (Oxford, England) 2005; 20(3):616-21.

• Choi MH, Kim HO, Cha SW, Koong MKK, Kim JY, Park CW. IVF comparison of ART outcomes in infertile PCOS women; in vitro maturation (IVM) vs. GnRH agonist vs. GnRH antagonist cycles. Clinical Experimental Reproductive Medicine December 2012; 39(4):S210.

• Choi MH, Lee SH, Kim HO, Cha SH, Kim JY, Yang KM, et al. Comparison of assisted reproductive technology outcomes in infertile women with polycystic ovary syndrome: In vitro maturation, GnRH agonist, and GnRH antagonist cycles. Clinical & Experimental Reproductive Medicine 2012; 39(4):166-71.

• Cota AM, Oliveira JB, Petersen CG, Mauri AL, Massaro FC, Silva LF, et al. GnRH agonist versus GnRH antagonist in assisted reproduction cycles: oocyte morphology. Reproductive Biology and Endocrinology 2012; 10:33.

• Lavorato HL, Oliveira JB, Petersen CG, Vagnini L, Mauri AL, Cavagna M, et al. GnRH agonist versus GnRH antagonist in IVF/ICSI cycles with recombinant LH supplementation: DNA fragmentation and apoptosis granulosa cells. European Journal of Obstetrics & Gynecology and Reproductive Biology 2012; 165:61-5.

• Depalo R, Lorusso F, Palmisano M, Bassi E, Totaro I, Vacca M, et al. Follicular growth and oocyte maturation in GnRH agonist and antagonist protocols for in vitro fertilisation and embryo transfer. Gynecological Endocrinology 2009; 25(5):328-34.

• El Sahwi S. GnRH agonists versus GnRH antagonists in controlled ovarian stimulation in ICSI trials. In: Book of Abstracts, 8th International Symposium on GnRH Analogues in Cancer and Human Reproduction. Salzburg, Austria. 2005:A65.

• Engmann L, DiLuigi A, Schmidt D, Nulsen D, Nulsen J, Benadiva C. The use of gonadotropin-releasing hormone (GnRH) agonist to induce oocyte maturation after cotreatment with GnRH antagonist in high-risk patients undergoing in vitro fertilization prevents the risk of ovarian hyperstimulation syndrome: a prospsective randomised controlled study. Fertility and Sterility 2008; 89(1):84-91.

• European and Middle East Orgalutran Study Group. Comparable clinical outcome using the GnRH antagonist ganirelix or a long protocol of the GnRH agonist triptorelin

49

for the prevention of premature LH surges in women undergoing ovarian stimulation. Human Reproduction (Oxford, England) 2001; 16(4):644-51.

• Sonntag B, Kiesel L, Nieschlag E, Behre HM. Association of inhibin B serum levels with parameters of follicular response in a randomized controlled trial comparing GnRH agonist versus antagonist protocols for ovarian hyperstimulation. Journal of Assisted Reproduction and Genetics 2004; 21(7):249-55.

• The European Orgalutran Study Group, Borm G, Mannaerts B. Treatment with the gonadotrophin-releasing hormone antagonist ganirelix in women undergoing ovarian stimulation with recombinant follicle stimulating hormone is effective, safe and convenient: results of a controlled, randomized, multicentre trial. Human Reproduction (Oxford, England) 15; 7:1490-8.

• Ferrari B, Pezzuto A, Barusi L, Coppola F. Follicular fluid vascular endothelial growth factor concentrations are increased during GnRH antagonist/FSH ovarian stimulation cycles. European Journal of Obstetrics & Gynecology and Reproductive Biology 2006; 124(1):70-6.

• Ferrari B, Pezzuto A, Barusi L, Coppola F. Gonadotrophin-releasing hormone antagonists increase follicular fluid insulin-like growth factor-I and vascular endothelial growth factor during ovarian stimulation cycles. Gynecological Endocrinology June 2006; 22(6):289-96.

• Ferrero S, Abbamonte L H, Privamera MR, Levi S, Venturini PL, Anserini P. Flexible GnRH antagonist protocol versus GnRH agonist long protocol in patients at high risk of ovarian hyperstimulation syndrome: A prospective randomized controlled trial. Fertility and Sterility 2010; 94 suppl 1(4):S28 Abstract no. O-92.

• Firouzabadi RD, Ahmadi S, Oskouian H, Davar R. Comparing GnRH agonist long protocol and GnRH antagonist protocol in outcome the first cycle of ART. Archives of Gynecology and Obstetrics 2010; 281(1):81-5.

• Fluker M, Grifo J, Leader A, Levy M, Meldrum D, Muasher SJ et al, for The North American Ganirelix Study Group. Efficacy and safety of ganirelix acetate versus leuprolide acetate in women undergoing controlled ovarian hyperstimulation. Fertility and Sterility 2001; 75(1):38-45

• Franco Jr JG, Baruffi RLR, Petersen CG, Mauri AL, Felipe V, Contart P. Comparison of ovarian stimulation with recombinant FSH After 2nd phase protocols with GnRH Analogs (I-estradiol + ganirelix versus II-nafarelin) [Comparacao da estimulacao ovariana com FSH recombinante apos protocolo de 2A fase com analogos do GNRH (I -estradiol + ganirelix versus II-nafarelin)]. Jornal Brasileiro de Reproducao Assistida 2003;7(1):26-32. [CRSREF: 2811070]

• Friedler S, Gilboa S, Schachter M, Raziel R, Strassburger D, Kasterstein E, et al.Luteal phase characteristics following GnRH antagonist or agonist treatment: a randomized comparative study. Human Reproduction (Oxford, England) 2003; 18Suppl 1:26. [CRSREF: 2811072]

50

• Gizzo S, Andrisani A, Esposito F, Noventa M, Di Gangi S, Angioni S, et al. Which luteal phase support is better for each IVF stimulation protocol to achieve the highest pregnancy rate? A superiority randomized clinical trial. Gynecological Endocrinology 2014; 30(12):902-8. [CRSREF: 2811074; DOI: 10.3109/09513590.2014.964638]

• Haydardedeoglu B, Kilicdag EB, Parlakgumus AH, Zeyneloglu HB. IVF/ICSI outcomes of the OCP plus GnRH agonist protocol versus the OCP plus GnRH antagonist fixed protocol in women with PCOS: a randomized trial. Archives of Gynecology and Obstetrics September 2012;286(3):763-769. [CRSREF: 2811076]

• Heijnen EM, Eijkemans MJ, De Klerk C, Polinder S, Beckers NG, Klinkert ER, et al. Amild treatment strategy for in-vitro fertilisation: a randomised non-inferiority trial. The Lancet 2007; 369:743-9. [CRSREF: 2811078]

• Hershko Klement A, Berkovitz A, Wiser A, Gonen O, Amichay K, Cohen I, et al. GnRH-antagonist programming versus GnRH agonist protocol: a randomized trial. European Journal of Obstetrics Gynecology and Reproductive Biology 2015;185:170-3. [CRSREF: 2811080]

• Hershko Klement A, Berkovitz A, Wiser A, Gonen O, Amichay K, Shulman A. Follicular estrogen for GnRH-antagonist protocol programming: a prospective randomized clinical trial. In: Fertility and Sterility. Vol. 1. 2013:S523. [CRSREF: 2811081]

• Hohmann FP, Macklon NS, Fauser BC. A randomized comparison of two ovarian stimulation protocols with gonadotropin-releasing hormone (GnRH) antagonist cotreatment for in vitro fertilization commencing recombinant follicle-stimulating hormone on cycle day 2 or 5 with the standard long GnRH agonist protocol. The Journal of Clinical Endocrinology and Metabolism 2003; 88(1):166-73. [CRSREF: 2811083]

• Hoseini FS, Mugahi SM, Akbari-Asbagh F, Eftekhari-Yazdi P, Aflatoonian B, Aghaee-Bakhtiari SH, et al. A randomized controlled trial of gonadotropin-releasing hormone antagonist in Iranian infertile couples: oocyte gene expression. Journal of Pharmaceutical Sciences 2014; 22:67. [CRSREF: 2811085]

• Hosseini MA, Aleyasin A, Saeedi H, Mahdavi A. Comparison of gonadotropin-releasing hormone agonists and antagonists in assisted reproduction cycles of polycystic ovarian syndrome patients. Journal of Obstetrics & Gynaecology Research 2010; 36(3):605-10. [CRSREF: 2811087]

• Hsieh YY, Chang CC, Tsai HD. Comparisons of different dosages of gonadotropin-releasing hormone (GnRH) antagonist, short-acting form and single, half-dose, long-acting form of GnRH agonist during controlled ovarian hyperstimulation and in vitro fertilization. Taiwan Journal of Obstetrics and Gynecology 2008; 47:66-74.

• Huirne JA, Van Loenen AC, Donnez J, Pirard C, Homburg R, Schats R, et al. Effect of an oral contraceptive pill on follicular development in IVF/ICSI patients receiving a GnRH antagonist: a randomized study. Reproductive Biomedicine Online 2006;13(2):235-45.

151

• Panay NA, Iammorrone E, Zosmer A, Tozer A, Hussain S. Does the prophylactic use of intravenous albumin prevent ovarian hyperstimulation syndrome? A randomized prospective study. Abstracts from the 15th Annual Meeting of the ESHRE, Tours, France 1999; 14:105.

• Shaker AG, Zosmer A, Dean N, Berik JS, Jacob HS, Tan SL. Comparison of intravenous albumin and transfer of fresh embryos with cryopreservation of all embryos for subsequent transfer in prevention of ovarian of ovarian hyperstimulation syndrome. Fertility and Sterility 1996; 65:992-6.

• Tan Sl, Balen A, El Hussein E, Campbell S, Jacobs HS. The administration of glucocorticoids for the prevention of ovarian hyperstimulation syndrome in invitro fertilisation: a prospective randomised study. Fertility and Sterility 1992; 58:378-83.

• Tehraninejad E, Hafezi M, Arabipoor A, Aziminekoo E, Chehrazi M, Bahmanabadi A. Comparison of cabergoline and intravenous albumin in the prevention of ovarian hyperstimulation syndrome: a randomized clinical trial.. Journal of Assisted Reproduction & Genetics. 2012; 29(3):259-64.

• Torabizadeh A, Vahidroodsari F, Ghorbanpour Z. Comparison of albumin and cabergoline in the prevention of ovarian hyperstimulation syndrome: A clinical trial study. Iranian Journal of Reproductive Medicine 2013; 11(10):837-42.

• Yakovenko SA, Zorina IV, Dmitrieva NV, Troshina MN, Apryshko VP, Voznesenskaya JV. Intravenous administration of calcium in ovarian hyperstimulation syndrome (OHSS) prevention. European Journal of Obstetrics Gynecology and Reproductive Biology 2011; 1:s20.

Additional references

• Aboulghar MA, Mansour RT. Ovarian hyperstimulation syndrome: classifications and critical analysis of preventive measures. Human Reproduction Update 2003;9(3):275-89.

• Cerrillo M, Pacheco A, Rodríguez S, Mayoral M, Ruiz M, García Velasco JA. Differential regulation of VEGF, Cadherin, and Angiopietin 2 by trigger oocyte maturation with GnRHa vs hCG in donors: try to explain the lower OHSS incidence. Abstracts of the 25th annual meeting of the ESHRE 2009; 24(1):i60.

• Chen D, Burmeister L, Goldschlag D, Rosenwaks Z. Ovarian hyperstimulation syndrome: strategies for prevention. Reproductive Biomedicine Online 2003; 7(1):43-9.

• D'Angelo A, Amso NN. Embryo freezing for preventing ovarian hyperstimulation syndrome. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD002806.

• D'Angelo A, Brown J, Amso NN. Coasting (withholding gonadotrophins) for preventing ovarian hyperstimulation syndrome. Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD002811.

52

• Kyono K, Fuchinoue K, Nakajo Y, Yagi A, Sasaki K. A prospective randomized study of three ovulation induction protocols for IVF: GnRH agonist versus antagonist with and without low dose hCG. Fertility and Sterility 2004; 82 Suppl: 31.

• Kyono K, Nakajo Y, Sasaki S, Kumagai S, Suzuki S. A prospective randomized study of three different controlled ovarian hyperstimulation (COH) protocols. Fertility andSterility 2005; 84 Suppl 1:299.

• Lainas TG, Petsas GK, Zorovilis IZ, Lliadis GS, Lainas GT, Gazlaris HE, et al. Initiation of GnRH antagonist on day 1 of stimulation as compared to the long agonist protocol in PCOS patients: a randomised controlled trial: effect on hormonal levels and follicular development. Human Reproduction 2007; 22(6):1540-6.

• Basly M, Achour R, Ben Jemaa S, Chnitir M, Messaoudi L, Chibani M, et al. Flexible Gnrh antagonist protocol versus Gnrh agonist long protocol in patients with polycystic ovary syndrome treated for IVF: a prospective randomised controlled trial (RCT). Internet Journal of Gynecology & Obstetrics 2012; 16(3):1.

• Lainas TG, Sfontouris IA, Zorzovilis IZ, Petsas GK, Lainas GT, Alexopoulou E, et al. Flexible GnRH antagonist protocol versus GnRH agonist long protocol in patients with polycystic ovary syndrome treated for IVF: a prospective randomised controlled trial (RCT). Human Reproduction 2010; 25(3):683-9.

• Lavorato HL, Oliveira JB, Petersen CG, Vagnini L, Maur AL, Cavagna M, et al. GnRH agonist versus GnRH antagonist in IVF/ICSI cycles with recombinant LH supplementation: DNA fragmentation and apoptosis in granulosa cells. European Journal of Obstetrics & Gynecology and Reproductive Biology 2012; 165(1):61 - 5.

• Lee TH, Wu MH, Chen HF, Chen MJ, Ho HN, Yang YS. Ovarian response and follicular development for single-dose and multiple-dose protocols for gonadotropin-releasing hormone antagonist administration. Fertility and Sterility 2005; 83(6):1700-7.

• Lin YH, Hwang JL, Seow KM, Huang LW, Hsieh BC, Tzeng CR. Comparison of outcome of clomiphene citrate/human menopausal gonadotropin/cetrorelix protocol and buserelin long protocol - a randomized study. Gynecological Endocrinology 2006;22(6):297-302.

• Loutradis D, Stefanidis K, Drakakis P, Milingos S, Antsaklis A, Michalas S. A modified gonadotropin-releasing hormone (GnRH) antagonist protocol failed to increase clinical pregnancy rates in comparison with the long GnRH protocol. Fertility and Sterility 2004; 82(5):1446-8.

• Marci R, Caserta D, Dolo V, Tatone C, Pavan A, Moscarini M. GnRH antagonist in IVF poor-responder patients: results of a randomized trial. Reproductive Biomedicine Online 2005; 11(2):189-93.

• Marci R, Caserta D, Farina M, Dessole S, Germond M, Tatone C, et al. The use of GnRH antagonist in ovarian stimulation for IVF cycles can achieve good pregnancy

53

rates in poor responder patients. Human Reproduction (Oxford, England) 2002;17:115-6.

• Martínez F, Clua E, Parera N, Rodríguez I, Boada M, Coroleu B. Prospective, randomized, comparative study of leuprorelin + human menopausal gonadotropins versus ganirelix + recombinant follicle-stimulating hormone in oocyte donors and pregnancy rates among the corresponding recipients. Gynecological Endocrinology 2008; 24(4):188-93.

• Mohamed KA, Davies WAR, Lashen H. Effect of gonadotropin-releasing hormone agonist and antagonist on steroidogenesis of low responders undergoing in vitro fertilization. Gynecological Endocrinology 2006; 22(2):57-62.

• Moraloglu O, Kilic S, Karayalçin R, Yuksel B, Tasdemir N, Ugur M. Comparison of GnRH agonists and antagonists in normo-responder IVF/ICSI in Turkish female patients. Advances in Therapy 2008; 25(3):266-73.

• Moshin V, Croitor M, Hotineanu A. GnRH antagonist versus long GnRH agonists protocol in PCOS patients undergoing IVF treatment. Abstracts of the 23rd Annual Meeting of the ESHRE, Lyon, France 2007; 22 Suppl 1:i121.

• Olivennes F, Belaisch-Allart, Emperor J, Dechaud H, S Alvarez S, Moreau L. Prospective randomized, controlled study of in vitro fertilization-embryo transfer with a single dose of a luteinizing hormone-releasing hormone (LH-RH) antagonist (cetrorelix) or a depot formula of an LH-RH agonist (triptorelin). Fertility and Sterility 2000; 73(2):314-20.

• Papanikolaou EG, Pados G, Grimbizis G, Bili E, Kyriazi L, Polyzos NP, et al. GnRH-agonist versus GnRH-antagonist IVF cycles: is the reproductive outcome affected by the incidence of progesterone elevation on the day of HCG triggering? A randomized prospective study. Human Reproduction 2012; 27(6):1822-8.

• Prapas Y, Petousis S, Dagklis T, Panagiotidis Y, Papatheodorou A, Assunta I, et al. GnRH antagonist versus long GnRH agonist protocol in poor IVF responders: a randomized clinical trial. European Journal of Obstetrics, Gynecology, & Reproductive Biology 2013; 166(1):43-6.

• Qiao J, Lu G, Zhang HW, Chen H, Ma C, Olofsson JI, et al. A randomized controlled trial of the GnRH antagonist ganirelix in Chinese normal responders: high efficacy and pregnancy rates. Gynecological Endocrinology 2012;28(10):800-4.

• Rabati BK, Zeidi SN. Investigation of pregnancy outcome and ovarian hyper stimulation syndrome prevention in agonist and antagonist gonadotropin-releasing hormone protocol. Journal of Research in Medical Sciences 2012; 17(11):1063-6.

• Revelli A, Chiadò A, Dalmasso P, Stabile V, Evangelista F, Basso G, et al. “Mild” vs. “long” protocol for controlled ovarian hyperstimulation in patients with expected poor ovarian responsiveness undergoing in vitro fertilization (IVF): a large prospective randomized trial. Journal of Assisted Reproduction and Genetics July 2014; 31(7):809-15.

54

• Rinaldi L, Lisi F, Selman H. Mild/minimal stimulation protocol for ovarian stimulation of patients at high risk of developing ovarian hyperstimulation syndrome. Journal of Endocrinological Investigation 2014; 37:65-70.

• Rombauts L, Healy D, Norman RJ. A comparative randomized trial to assess the impact of oral contraceptive pretreatment on follicular growth and hormone profiles in GnRH antagonist-treated patients. Human Reproduction (Oxford, England) 2006;21(1):95-103.

• Sauer MV, Thornton MH, Schoolcraft W, Frishman GN. Comparative efficacy and safety of cetrorelix with or without mid-cycle recombinant LH and leuprolide acetate for inhibition of premature LH surges in assisted reproduction. Reproductive Biomedicine Online 2004; 9(5):487-93.

• Sbracia M, Colabianchi J, Giallonardo A, Giannini P, Piscitelli C, Morgia F, et al. Cetrorelix protocol versus gonadotropin-releasing hormone analog suppression long protocol for superovulation in intracytoplasmic sperm injection patients older than 40. Fertility and Sterility 2009; 91(5):1842-7.

• Serafini P, Yadid I, Alegretti J, Panzan M, Cosloversusky M, Motta E. A prospective, randomized trial of three ovulation induction protocols for IVF including a novel approach with low-dose HCG and GnRH antagonist in the mid-late follicular phase. Human Reproduction (Oxford, England) 2003; 18:1.

• Serafini P, Yadid I, Motta ELA, Alegretti JR, Fioavanti J, Coslovsky M. Ovarian stimulation with daily late follicular phase administration of low dose human chorionic gonadotropin for in vitro fertilization: a prospective randomized trial. Fertility and Sterility 2006; 86(4):830-8.

• Stenbaek DS, Toftager M, Hjordt LV, Jensen PS, Holst KK, Bryndorf T, et al. Mental distress and personality in women undergoing GnRH agonist versus GnRH antagonist protocols for assisted reproductive technology. Human Reproduction 2015; 30(1):103-10.

• Sunkara S, Coomarasamy A, Faris R, Braude P, Khalaf Y. Effectiveness of the GnRH agonist long, GnRH agonist short and GnRH antagonist regimens in poor responders undergoing IVF treatment: a three arm randomised controlled trial. In: Human Reproduction. Vol. 28. 2013:i348.

• Sunkara SK, Coomarasamy A, Faris R, Braude P, Khalaf Y. Long gonadotropin-releasing hormone agonist versus short agonist versus antagonist regimens in poor responders undergoing in vitro fertilization: A randomized controlled trial. Fertility and Sterility 2014; 101(1):147-53.

• Tazegül A, Görkemli H, Ozdemir S, Aktan TM. Comparison of multiple dose GnRH antagonist and minidose long agonist protocols in poor responders undergoing in vitro fertilization: a randomized controlled trial. Archives of Gynecology and Obstetrics 2008; 278(5):467-72.

55

• Tehraninejad ES, Nasiri R, Rashid B, Haghollahi F, Ataxia M. Comparison of GnRH antagonist with long GnRH agonist protocol after OCP pretreatment in PCOs patients. Archives of Gynecology and Obstetrics 2010; 282(3):319-25.

• Nezamabadi AG, Tehraninejad ES, Rashidi B. GnRH Antagonist versus Agonist in Normoresponders Undergoing ICSI: A Randomized Clinical Trial in Iran. International Journal of Fertility and Sterility 2013; 7(1):106.

• Tehraninejad E, Nezamabadi AG, Rashidi B, Sohrabi M, Bagheri M, Haghollahi F, et al.. GnRH antagonist versus agonist in normoresponders undergoing ICSI: a randomized clinical trial in Iran. Iranian Journal of Reproductive Medicine 2011;9(3):171-6

• Toltager M, Bogstad J, Lossl, K, et al. Pregnancy rates and risk of ovarian hyperstimulation syndrome (OHSS) in a fixed GnRH-antagonist versus GnRH-agonist protocol: randomised controlled trial including 1099 first IVF/ICSI CYCLES. In: Abstract of the 31st annual meeting of ESHRE I Lisbon, Portigal. 2015:i94.

• Xavier P, Gamboa C, Calejo L, Silva J, Stevenson D, Nunes A, et al. A randomised study of GnRH antagonist (cetrorelix) versus agonist (busereline) for controlled ovarian stimulation: effect on safety and efficacy. Eurpean Journal of Obstetrics, Gynecology, and Reproductive Biology 2005; 120(2):185-9.

• Ye H, Huang G, Zeng P, Pei L. IVF/ICSI outcomes between cycles with luteal estradiol (E2) pre-treatment before GnRH antagonist protocol and standard long GnRH agonist protocol: a prospective and randomized study. Journal of Assisted Reproduction and Genetics 2009; 2(3):105-11.

Excluded studies

• Ashrafi M, Mohammadzadeh A, Ezabadi Z, Baghestani AR. A comparative study of GnRH-ant and GnRH-ag protocols on IVF-ICSI in PCOD patients. In: Book of Abstracts, 18th World Congress on Fertility and Sterility (IFFS 2004), Montreal Canada. 2004.

• Bonduelle M, Oberyé J, Mannaerts B, Devroey P. Large prospective, pregnancy and infant follow-up trial assures the health of 1000 fetuses conceived after treatment with the GnRH antagonist ganirelix during controlled ovarian stimulation. Human Reproduction 2010; 25(6):1433-40.

• Cattani R, Cela V, Cristello F, Matteucci C, Valentino V, Artini P. Efficacy and safety of gonadotrophin releasing hormone (GnRH) antagonist administration in infertile women during controlled ovarian hyperstimulation. In: Gynecological Endocrinology. 8th World Congress of Gynecological Endocrinology, Florence, Italy, 2000 edition. Vol. 14. 2000:212.

• Causio F, Sarcina E, Leonetti T. GnRH agonist versus GnRH antagonist in an IVF program: luteal phase hormonal characteristics. Human Reproduction 2004; 19:i103.

56

• Crosignani PG, Somigliana E. Effect of GnRH antagonists in FSH mildly stimulated intrauterine insemination cycles: a multi centre randomized trial. Human Reproduction 2007; 22(2):500-5.

• D'Amato G, Caroppo E, Pasquadibisceglie A, Carone D, Vitti A, Vizziello GM. A novel protocol of ovulation induction with delayed gonadotropin-releasing hormone antagonist administration combined with high-dose recombinant follicle-stimulating hormone and clomiphene citrate for poor responders and women over 35 years. Fertility and Sterility 2004; 81(6):1572-7.

• Davar R, Rahsepar M, Rahmani E. A comparative study of luteal estradiol pre-treatment in GnRH antagonist protocols and in micro dose flare protocols for poor responding patients. Fertlity and Sterility 2012; 6(1):107.

• De Klerk C, Macklon NS, Heijnen EMEW, Eijkemans MJC, Fauser BCJM, Passchier J, Hunfeld JAM. The psychological impact of IVF failure after two or more cycles of IVF with a mild versus standard treatment strategy. Human Reproduction 2007;22(9):2554-8.

• Dudley PS, Thyer AC, Davis LB, Klein NA, Criniti AR, Soules MR. A new IVF stimulation protocol improves live birth rate in women with diminished ovarian reserve (DOR). Fertility and Sterility September 2010; 94(4):S85-S86.

• Eijkemans MJ, Heijnen EM, De Klerk C, Habbema JD, Fauser BC. Comparison of different treatment strategies in IVF with cumulative live birth over a given period of time as the primary end-point: methodological considerations on a randomized controlled non-inferiority trial. Human Reproduction (Oxford, England) 2006;21(2):344-52.

• Engmann L, DiLuigi A, Schmidt D, Benadiva C, Maier D, Nulsen J. The effect of lutealphase vaginal estradiol supplementation on the success of in vitro fertilization treatment: a prospective randomized study. Fertility and Sterility 2008; 89(3):554-61.

• Evangelio PM, Buendicho IE, Yeste AMM, Gustem RB, Egea IB, Hernandez NC. Randomized prospective study on the effect of the addition of business cycles exogenous LH IVF/ICSI GnRH antagonist predictors in patients with low response [Estudio prospectivo aleatorizado sobre el efecto de la adicion de actividad LH exogena en ciclos FIV/ICSI con antagonistas de GnRH en pacientes con factores predictivos de baja respuesta]. Revista Iberoamericana de Fertilidad 2011; 28(3):219-27.

• Fabregues F, Iraola A, Casals G, Peralta S, Creus M, Balasch J. Evaluation of GnRH agonists and antagonists in tertiary prevention of OHSS. Clinical, neurohormonal and vasoactive effects in the luteal phase in high risk patients. Human Reproduction 2012; 27(2):ii26-ii28.

• Ficicioglu C, Kumbak B, Akcin O. Comparison of follicular fluid and serum cytokine concentrations in women undergoing assisted reproductive treatment with GnRH agonist long and antagonist protocols. Gynecological Endocrinology 2010; 26(3):181-6.

57

• Freitas GC, Cavagna M, Dzik A, Soares JB, Szterenfeld C, Izzo VM. Gonadotropin-releasing hormone (GnRH)-agonist versus GnRH-antagonist in ovarian stimulation for assisted reproductive techniques: results of a prospective randomized trial. Fertility and Sterility 2004; 82 Suppl: 231-2.

• Ghosh M, Shirazee HH, Vijay PK, Chakravarty BN. Comparative evaluation of CC/FSH with single dose antagonist versus conventional long protocol gonadotrophin stimulation for IVF in women with several attempts of failed IUI for unexplained infertility. Human Reproduction (Oxford, England) 2003; 18 Suppl 1:114-5.

• Gordts S, Puttemans P, Campo R, Valkenburg M, Gordts S. A prospective randomized study comparing a GnRH-antagonist versus a GnRH-agonist short protocol for ovarian stimulation in patients referred for IVF. Fertility and Sterility September 2011; 96(3):S176.

• Guivarc’h-Levêque A, Arvis P, Bouchet JL, Broux PL, Moy L, Priou G, et al. Efficiency of antagonist IVF cycle programming by estrogens [Efficacité de la programmation des cycles FIV en antagonistes par les estrogenes]. Gynécologie Obstétrique & Fertilité 2010; 38:18-22.

• Ibrahim ZM, Mohamed Youssef HY, Elbialy MM, Farrag MM. Micro-dose flare-up gonadotrophin-releasing hormone (GnRH) agonist vs. flexible gonadotrophin-releasing hormone (GnRH) antagonist protocol in patient with poor ovarian reserve. Middle East Fertility Society Journal 2011; 16:272-277.

• Jindal A, Singh R. A prospective randomised controlled study comparing a low-cost antagonist protocol using oral ovulation inducing agents in IVF-ICSI cycles with a standard agonist long protocol. Fertility and Sterility October 2013; 100(3):S273.

• Karimzadeh MA, Mashayekhy M, Mohammadian F, Moghaddam FM. Comparison of mild and microdose GnRH agonist flare protocols on IVF outcome in poor responders. Archives of Gynecology and Obstetrics 2011; 283:1159-64.

• Kdous M, Chaker A, Bouyahia M, Zhioua F, Zhioua A. Increased risk of early pregnancy loss and lower live birth rate with GnRH antagonists vs. long GNRH agonist protocol in PCOS women undergoing controlled ovarian hyperstimulation. La Tunisie Medicale 2009; 87(12):834-42.

• Kim YJ, Ku SY, Jee BC, Suh CS, Kim SH, Choi YM, et al. A comparative study on the outcomes of in vitro fertilization between women with polycystic ovary syndrome and those with sonographic polycystic ovary-only in GnRH antagonist cycles. Archives of Gynecology and Obstetrics 2010; 282(2):199-205. [CRSREF: 2811223; PubMed: 20182736

• Lee JR, Kim SH, Kim SM, Jee BC, Ku SY, Suh CS, et al. Follicular fluid anti-Müllerian hormone and inhibin B concentrations: comparison between gonadotropin-releasing hormone (GnRH) agonist and GnRH antagonist cycles. Fertility and Sterility 2008;89(4):860-7.

58

• Lin Y, Kahn JA, Hillensjo T. Is there a difference in the function of granulosa-luteal cells in patients undergoing in-vitro fertilization either with gonadotrophin-releasing hormone agonist or gonadotrophin-releasing hormone antagonist? Human Reproduction (Oxford, England) 1999; 14(4):885-8.

• Londra L, Inza R, Lombardi E, Marconi G, Young E, Kenny A. GnRh antagonist versus GnRh agonist in good prognosis IVF patients. Human Reproduction 2003; 18Suppl 1:114.

• Maldonado LG, Setti AS, Franco JG, Braga DPAF, Figueira RCS, Iaconelli A, et al. Pituitary suppression with GnRH agonist on alternate days: can costs, effectiveness and comfort be brought together? Human Reproduction 2011; 26(1):i151.

• Maldonado LGL, Franco JG, Setti AS, Iaconelli A, Borges E. Cost-effectiveness comparison between pituitary down-regulation with a gonadotropin-releasing hormone agonist short regimen on alternate days and an antagonist protocol for assisted fertilization treatments. Fertility and Sterility May 2013; 99(6):1615-1622.

• Malhotra N, Singh N. Microdose GnRH agonist flare-up versus flexible GnRH antagonist protocol in poor responders undergoing in-vitro fertilization (IVF) cycles: a randomized controlled trial. Fertility and Sterility 2013; 100(3):S106.

• Mohsen IA, El Din RE. Minimal stimulation protocol using letrozole versus microdose flare up GnRH agonist protocol in women with poor ovarian response undergoing ICSI. Gynecological Endocrinology 2013; 29(2):105-8.

• Orvieto R, Volodarsky M, Hod E, Homburg R, Rabinson J, Zohav E, et al. Controlled ovarian hyperstimulation using multi-dose gonadotropin-releasing hormone (GnRH) antagonist results in less systemic inflammation than the GnRH-agonist long protocol. Gynecological Endocrinology 2007; 23(8):494-6.

• Orvieto R, Meltzer S, Rabinson J. GnRH agonist versus GnRH antagonist in ovarian stimulation: the role of endometrial receptivity. Fertility and Sterility 2008; 90(4):1294-6.

• Ozdogan S, Ozdegirmenci O, Dilbaz S, Demir B, Cinar O, Dilbaz B, et al. A randomized prospective study of a gonadotropin-releasing hormone antagonist versus agonist microdose flare-up protocol in poor responder patients. Human Reproduction 2012; 27(2):ii302.

• Pabuccu R, Onalan G, Selam B, Ceyhan T, Akar M, Onalan R. Comparison of GnRH agonist and antagonist protocols among patients with mild-moderate endometriosis and endometrioma: a novel clinical approach. Fertility and Sterility 2005; 84 Suppl 1:197-8.

• Perino M, Abate A, Brigandi A, Magnoli D, Abate F. Comparison between the GnRH antagonist ganirelix and the GnRH agonist buserelin: a prospective randomized controlled study. Human Reproduction (Oxford, England) 2002; 17:33.

59

• Pinto F, Oliveira C, Cardoso MF, Teixeira-da-Silva J, Silva J, Sousa M, et al. Impact of GnRH ovarian stimulation protocols on intra-cytoplasmic sperm injection outcomes. Reproductive Biology and Endocrinology 2009; 7(5):1-10.

• Polinder S, Heijnen EM, Macklon NS, Habbema JD, Fauser BJ, Eijkemans MJ. Cost-effectiveness of a mild compared with a standard strategy for IVF: a randomized comparison using cumulative term live birth as the primary endpoint. Human Reproduction 2008;23(2):316-23.

• Prapas N, Prapas Y, Panagiotidis Y, Prapa S, Vanderzwalmen P, Schoysman R, et al. GnRH agonist versus GnRH antagonist in oocyte donation cycles: a prospective randomized study. Human Reproduction (Oxford, England) 2005; 20(6):1516-20. [

• Saini P, Saini A. New protocol of ovulation induction with GnRH antagonist comparedwith GnRH analogue long protocol in IVFET/ICSI cycles. Abstracts of the 26th Annual Meeting of ESHRE, Rome, Italy, 27 June – 30 June, 2010 June 2010;26:i317.

• Shamma F, Grossman M, Abuzeid M, al Hosn L, Ayers J, Fakih M. Comparison of daily ganirelix administration to a long protocol agonist for controlled ovarian hyperstimulation in oocyte donors: the results of a prospective randomized controlled trial. Fertility and Sterility 2003; 80 Suppl 3:37-8.

• Tanaka A, Nagayoshi M, Tanaka I. Selection of an optimal controlled ovarian hyperstimulation method in relation to the number of antral follicles in patients less than 40 years old. Fertility and Sterility September 2014; 102(3):e223.

• Tiras B, Leylek OA, Halicigil C, Saltik A, Kavci N. Does single dose GNRH agonist administration after oocyte pick-up in antagonist cycles improve endometrial receptivity and pregnancy rates? Fertility and Sterility October 2013; 100(3):S59-S60.

• Verpoest W, Vloeberghs V, Staessen C, Devos A, De Rycke M, Bonduelle M, et al. The effect of the type of ovarian stimulation protocol on PGD results: a prospective randomised trial. Human Reproduction 2013; 28(1):i44.

• Vlaisavljevic V, Reljic M, Lovrec VG, Kovacic B. Comparable effectiveness using flexible single-dose GnRH antagonist (cetrorelix) and single-dose long GnRH agonist (goserelin) protocol for IVF cycles--a prospective, randomized study. Reproductive Biomedicine Online 2003; 7(3):301-8.

• Wang B, Sun HX, Hu YL, Chen H, Zhang NY. Application of GnRH-antagonist to IVF-ET for patients with poor ovarian response [GnRH拮抗剂用于卵巢反应不良患者的体

外受精胚胎移植]. National Journal of Andrology May 2008; 14(5):423-6.

• Willman SP, Kliman HJ. Comparison of the luteal phase after pituitary suppression with GnRH-agonist versus GnRH antagonist in controlled ovarian stimulation. Fertility and Sterility 2005; 84 Suppl: 308.

• Zikopoulos K, Kaponis A, Adonakis G, Sotiriadis A, Kalantaridou S, Georgiou I, et al. A prospective randomized study comparing gonadotropin-releasing hormone agonists

60

or gonadotropin-releasing hormone antagonists in couples with unexplained infertility and/or mild oligozoospermia. Fertility and Sterility 2005;83(5):1354-62. [

Additional references • Al-Inany H, Aboulghar MA, Mansour RT, Serour GI. Optimizing GnRH antagonist

administration: meta-analysis of fixed versus flexible protocol. Reproductive biomedicine online 2005; 10(5):567-70. [PubMed: 15949209]

• Albano C, Smitz J, Camus M, Riethmuller-Winzen H, Siebert-Weiger M, Diedrich K, et al. Hormonal profile during the follicular phase in cycles stimulated with a combination of human menopausal gonadotrophin and gonadotrophin-releasing hormone antagonist (cetrorelix). Human Reproduction (Oxford, England) 1996; 11(10):2114-8.

• Bosch, E., Valencia, I., Escudero, E., et al. Premature luteinization during gonadotropin-releasing hormone antagonist cycles and its relationship with in vitro fertilization outcome.. Fertil.Steril 2003; 80.

• Daya S. Gonadotropin releasing hormone agonist protocols for pituitary desensitization in in vitro fertilization and gamete intrafallopian transfer cycles. Cochrane Database of Systematic Reviews 2000, Issue 1. Art. No.: CD001299. DOI: 10.1002/14651858.CD001299.

• Delvigne A, Rozenberg S. Epidemiology and prevention of ovarian hyperstimulation syndrome (OHSS): a review. Hum Reprod Update 2002;8:559-77.

• J. M. Duijkers, C. Klipping, W. N. P. Willemsen et al. Single and multiple dose pharmacokinetics and pharmacodynamics of the gonadotrophin-releasing hormone antagonist Cetrorelix in healthy female volunteers. Human Reproduction 1998;13(9):2392-2398.

• Felberbaum RE, Reissmann T, Kuper W, Bauer O, al Hasani S, Diedrich C, et al. Preserved pituitary response under ovarian stimulation with hMG and GnRH-antagonists (Cetrorelix) in women with tubal infertility. European Journal of Obstetrics, Gynecology, and Reproductive Biology 1995; 61(2):151-5.

• Franco JG Jr, Baruffi RLR, Mauri AL, Petersen CG, Felipe V, Cornicelli J, et al. GnRH agonist versus GnRH antagonist in poor ovarian responders: a meta-analysis. Reproductive Biomedicine Online 2006; 13(5):618-27.

• Griesinger G, Venetis CA, Marx T, Diedrich K, Tarlatzis BC, Kolibianakis EM. Oral contraceptive pill pretreatment in ovarian stimulation with GnRH antagonists for IVF: asystematic review and meta-analysis. Fertility and Sterility 2008; 90(4):1055.

• Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ 2003; 327:557-60.

• Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane-handbook.org.

61

• Hughes EG, Fedorkow DM, Daya S, Sagle MA, Van de Koppel P, Collins JA. The routine use of gonadotropin-releasing hormone agonists prior to in vitro fertilization and gamete intrafallopian transfer: a meta-analysis of randomized trials. Fertility and Sterility 1992; 58:888-96.

• Huirne JA, Homburg R, Lambalk CB. Are GnRH antagonists comparable to agonists for use in IVF? Hum Reprod 2007; 11:2805-2813.

• Kolibianakis, E.M., Albano, C., Camus, M., Tournaye, H., Van Steirteghem, A. C. and Devroey, P. Initiation of gonadotropin-releasing hormone antagonist on day 1 as compared to day 6 of stimulation: effect on hormonal levels and follicular development in in vitro fertilization cycles.. J.Clin.Endocrinol.Metab 2003; 88:5632-5637.

• Kolibianakis1,E.M. Zikopoulos, K., Smitz,J., Camus, M., Tournaye, H., Van Steirteghemand A.C., Devroey,P. Elevated progesterone at initiation of stimulation is associated with a lower ongoing pregnancy rate after IVF using GnRH antagonists. Human Reproduction 2004; 19(7):1525-1529. [Other: ]

• Kolibianakis EM, Collins J, Tarlatzis BC, Devroey P, Diedrich K, Griesinger G. Among patients treated for IVF with gonadotrophins and GnRH analogues, is the probability of live birth dependent on the type of analogue used? A systematic review and meta-analysis. Human reproduction update 2006; 12(6):651-71. [PubMed: 16920869]

• Mathur R, Kailasam C, Jenkins J. Review of the evidence base strategies to prevent ovarian hyperstimulation syndrome. Hum Fertil 2007; 10:75-85.

• Moher D, Jones A, Cook DJ, Jadad AR, Moher M, Tugwell P, Klassen TP. Does quality of reports of randomised trials affect estimates of intervention efficacy reported in meta-analyses? The Lancet 1999; 352(9128):609-18.

• Mozes M, Bogokowsky H, Antebi E, Lunenfeld B, Rabau E, Serr DM,et al. Thromboembolic phenomena after ovarian stimulation with human gonadotrophins. Lancet 1965;2:1213-5.

• Nikolettos N, Al-Hasani S, Felderbaum R, Demirel LC, Kupker W, Montzka P, et al. Gonadotropin-releasing hormone antagonist protocol: a novel method of ovarian stimulation in poor responders. European Journal of Obstetrics, Gynecology, and Reproductive Biology 2001; 97:202-7.

• Olivennes F, Fanchin R, Bouchard P, de Ziegler D, Taieb J, Selva J. The single or dual administration of the gonadotrophin-releasing hormone antagonist cetrorelix in an in-vitro fertilisation-embryo transfer program. Fertility and Sterility 1994; 62(3):468-76.

• Olivennes F, Alvarez S, Bouchard P, Fanchin R, Salat-Baroux J, Frydman R. The use of GnRH antagonist (Cetrorelix) in a single dose protocol in IVF-embryo transfer: a dose finding study of 3 versus 2mg. Human Reproduction (Oxford, England) 1998;13(9):2411-4.

62

• Orvieto R, Rabinson J, Meltcer S, Gemer O, Anteby EY, Zohav E. Does physicians' experience influence in vitro fertilization success in patients undergoing controlled ovarian hyperstimulation with GnRH antagonists? Fertility and sterility 2008; 89(3):736-7. [PubMed: 17498708]

• Marco Sbracia, Julio Colabianchi, Annalise Giallonardo, Pierluigi Giannini, Claudio Piscitelli, Francesco Morgia, Monica Montigiani and Mauro Schimberni. Cetrorelix protocol versus gonadotropin-releasing hormone analog suppression long protocol for superovulation in intracytoplasmic sperm injection patients older than 40. Fertility and Sterility May 2009; 91(5).

• Kok-Min Seow a, b Yu-Hung Lin a, b Bih-Chwen Hsieh a, b Lee-Wen Huang a–cShih-Chia Huang a Chin-Yu Chen a Pei-Hsin Chen a Chii-Ruey Tzeng cJiann-Loung Hwang a, c. Characteristics of Progesterone Changes in Women with Subtle Progesterone Rise in Recombinant Follicle-Stimulating Hormone and Gonadotropin-Releasing Hormone Antagonist Cycle. Gynecol Obstet Invest 2010; 70:64–68.

• Shoham, Z. The clinical therapeutic window for luteinizing hormone in controlled ovarian stimulation. Fertil.Steril. 2002; 77:1170-1177.

• Smit JG, Sterrenburg MD, Eijkemans MJC, Al-Inany HG, Youssef MA, Broekmans FJM. The role of the fixed GnRH-antagonist protocol in improvement of pregnancy outcomes after IVF: a meta-analysis. Abstracts of the 27th Annual Meeting of ESHRE, Stockholm, Sweden, 3 July – 6 July, 2011.

• Smulders B, van Oirschot SM, Farquhar C, Rombauts L, Kremer JAM. Oral contraceptive pill, progestogen or estrogen pre-treatment for ovarian stimulation protocols for women undergoing assisted reproductive techniques. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD006109. DOI: 10.1002/14651858.CD006109.pub2.

• Tremellen KP, Lane M. Avoidance of weekend oocyte retrievals during GnRH antagonist treatment by simple advancement or delay of hCG administration does not adversely affect IVF live birth outcomes. Human. Reprod. 2010 may; 25(5):1219-24.

• Youssef M, Aboulfoutouh L, Van Der Veen F, Van Wely M. Could mild/minimal ovarian stimulation-IVF displace conventional IVF in poor responder women undergoing IVF/ICSI treatment cycles: Systematic review & meta-analysis. Human Reproduction 2012; 27.

63

Chapter 3

Can dopamine agonist at a low dose reduce ovarian hyperstimulation syndrome in women at risk

undergoing ICSI treatment cycles? A randomized

controlled study.

Shaltout A, Shohyab A, Youssef MA.

Eur J Obstet Gynecol Reprod Biol. 2012; 165(2):254-8.

64

Abstract

Objective: Dopamine agonists were proposed as a preventive strategy for severe ovarian.

The aim of this randomized controlled study is to evaluate the role of dopamine agonist at

lower doses (0.25 mg) as a preventive strategy of severe hyperstimulation syndrome (OHSS)

in women at high risk in IVF/ICSI treatment cycles.

Study design: Two hundred women at risk to develop OHSS undergoing IVF/ICSI treatment

cycle were included; the study group received 0.25 mg of cabergoline for 8 days from the day

of HCG administration versus no treatment for the prevention of OHSS. Reduction of the

incidence OHSS was the primary outcome.

Results: The overall incidence of OHSS was significantly reduced, almost 50%, in

cabergoline group in comparison with control group (RR: 0.5, 95% CI: 0.29–0.83), with

absolute risk reduction following cabergoline administration 11% (ARR: 0.11, 95% CI: 1.09–

20.91). The corresponding number needed to treat (NNT) was 9.

Conclusion: Prophylactic treatment with the dopamine agonist, cabergoline, at lower doses

(0.25 mg) reduces the incidence of OHSS in women at high risk undergoing IVF/ICSI

treatment.

65

Introduction

Ovarian hyperstimulation syndrome (OHSS) is a potential complication of ovarian induction

therapy affecting 1–14% of all IVF/ICSI cycles [Garcia-Velasco and Pellicer 2003]. As the

pathophysiology of this syndrome is not clearly understood [Aboulghar 2009; Garcia-Velasco

2009; Alper et al., 2009; Go’mez et al., 2010; Nastri et al., 2010], different strategies have

been tried to prevent OHSS, such as cycle cancellation, coasting [Garcia-Velasco 2006],

intravenous fluid administration around the time of oocyte retrieval [Youssef et al., 2011],

GnRH agonist for final oocyte maturation triggering in GnRH antagonist cycles [Youssef et

al., 2011], natural-cycle IVF or in vitro oocyte maturation [Edwards 2007], recombinant HCG

instead of urinary HCG [Youssef et al., 2011], metformin [Khattab et al., 2006], elective

cryopreservation of all embryos and embryo transfer in future cycles [Vyjayanthi et al., 2006],

and, recently, GnRH antagonist for pituitary desensitization instead of long GnRH agonist [Al-

Inany et al., 2011]. Unfortunately, none of the strategies currently employed completely

prevents severe OHSS after HCG administration.

Capillary permeability is the end step of the cascade of the pathophysiology of OHSS and is

associated with third space fluid accumulation and fluid shift. Vascular endothelial growth

factor (VEGF) is a vasoactive mediator which increases capillary permeability and is

expressed at a higher level in the granulosa cells [Rizk et al., 1997]. The administration of a

dopamine agonist in immature rats at low doses simultaneously with HCG prevented an

increase in vascular permeability and did not affect angiogenesis [Ata et al., 2009]; the effect

was due to the availability of dopamine type 2 receptors [Soares et al., 2008]. Dopamine

agonists prevent the phosphorylation of VEGF receptor 2 and reduce the in vitro and in vivo

release of vasoactive angiogenic agents. As a result, vascular permeability is also reduced

[Gomez et al., 2006; Rollene et al., 2009; Busco et al., 2010]. Consequently, dopamine

agonist at a daily dose of 0.5 mg has been supposed to be a potential new strategy to

prevent OHSS and reduce its severity [Alvarez et al., 2007; Spitzer et al., 2011].

Cabergoline, an ergot derivative, is a potent dopamine receptor agonist on D2 receptors. It is

frequently used as a first-line agent in the management of prolactinomas due to higher

affinity for D2 receptor sites, less severe side effects, and more convenient dosing schedule

than the older treatment, bromocriptine. Many studies have evaluated cabergoline as a

preventive strategy to reduce the incidence of OHSS using varying doses and regimens.

Concerns arose about the risk of cabergoline dose and duration of treatment in terms of

endometrial angiogenesis, implantation, pregnancy and congenital anomalies. We assumed

that 0.25 mg of cabergoline could safely and effectively reduce the incidence of OHSS in

women undergoing ICSI treatment without harming treated women or their babies.

66

The aim of this randomized controlled study was to evaluate the efficacy and safety of a low

dose (0.25 mg) of the dopamine agonist, cabergoline, in the prevention of OHSS in women

at risk of developing OHSS when undergoing ICSI treatment cycles.

Materials and Methods

Two hundred infertile couples undergoing ICSI at a private IVF/ICSI center (Samir Abbass,

Jeddah, SA) and at risk of developing OHSS were included between January 2007 and

October 2010. The risk of developing OHSS was defined as follows: E2 level on day of HCG

> 3500 pg/ml, and with ≥ 20 follicles > 12 mm. Patients with E2 ≥ 5000 pg/ml were excluded

from the study. The protocol was approved by the Internal Ethical Research Committee and

patients were included after signing a written consent form.

A long mid-luteal GnRH agonist protocol, 0.1 mg triptorelin SC (Decapeptyl; Ferring,

Germany) was used for pituitary downregulation in both groups. Once pituitary

downregulation had been confirmed, controlled ovarian hyperstimulation (COH) was started

using fixed dose of HMG, 150–225 IU (Menogon 75 IU, IM injections, Ferring, Germany), for

5 days; the dose was then adjusted according to response. When three leading follicles

reached 18 mm, final oocyte maturation was triggered with a single dose of 5000 IU of HCG,

which is the policy of our center. On the day of HCG administration, couples were allocated

by a series of computer generated random numbers into two groups: the cabergoline group

(Group I; n = 100), received 0.25 mg daily for 8 days and the non-cabergoline group (Group

II; n = 100), did not receive cabergoline. Transvaginal guided oocyte retrieval was performed

34–36 h later. All the patients received 500 ml of hydroxyethyl starch (HES) over 30 min as a

routine strategy in our center on the day of ovum pickup. Ultrasound guided transfer (ET) of

2–3 embryos was performed 72 h later. The luteal phase was supported with 400 mg

progesterone vaginal pessaries (Cyclogest; Cox Pharmaceuticals, Whiddon Valley, UK),

twice daily up to the day of pregnancy test. Hemoconcentration, the presence of ascites,

measuring the perpendicular diameter of free fluid in the pouch of Douglas, and the ovarian

volume were reported in both groups on the day of ET and one week later.

The primary outcome measure was reduction of the overall incidence of OHSS according to

Golan’s classification [Golan et al., 1989] and secondary outcome measures included severe

and mild to moderate OHSS, early (<7–9 days) and late OHSS (≥ 10 days), number of

retrieved oocytes, number of mature oocytes, hospitalization rate due to severe OHSS,

fertilization rate, clinical pregnancy rate (defined as presence of fetal heart pulsation 2 weeks

after a positive b-HCG test), live birth rate, and incidence of congenital anomalies.

67

Statistical analysis was performed using SPSS (Version 17, SPSS Inc., Chicago, IL, USA).

Dichotomous outcomes were expressed as percentages and relative ratios (RR) with 95%

CI. Continuous outcomes were expressed as mean ± SD. Chi-square test and Student’s t

tests were performed to evaluate the statistical differences between the variables. A P value

of ≤ 0.05 was considered statistically significant. All outcomes were calculated according to

intention to treat analysis.

Results

A total of 250 patients were assessed for eligibility, and 50 patients were not included. Two

hundred patients were randomized: 100 women to the cabergoline group and 100 women to

the control group. Embryo transfer was cancelled due to failure to recover oocytes during

oocyte retrieval in 2 cases and 3 cases, and failure of fertilization in 2 cases and 1 case, in

the cabergoline and non-cabergoline groups, respectively. One woman discontinued

cabergoline because she experienced severe nausea and vomiting (Fig. 1). There was no

evidence of a statistically significant difference between both groups as regards their age,

BMI and cause of infertility (Table 1).

The actual incidence of OHSS was 10% in the cabergoline group and 21% in the control

group. Thus the incidence of OHSS was significantly reduced, by almost 50%, in the

cabergoline group in comparison with the control group (RR: 0.5, 95% CI: 0.29–0.83), with

an absolute risk reduction following cabergoline administration of 11% (ARR: 0.11, 95% CI:

1.09–20.91). The corresponding number needed to treat (NNT) was 9. OHSS was stratified

into mild, moderate and severe according to Golan’s classification [23]. Although the

incidence of both severe and moderate OHSS was almost 30% lower in the cabergoline

group, this difference was not statistically significant (RR: 0.33, 95% CI: 0.03–3.19 and 0.34,

95% CI: 0.10–1.10). As regards the onset of OHSS, we could stratify the OHSS cases into

an early (≤ 7–9 days from day of HCG administration) and a late (10 days) onset. While

cabergoline markedly reduced early onset OHSS, there was no statistical evidence of a

reduction of late onset OHSS in comparison with the control group. There was evidence of a

statistically significant increase in the signs of OHSS on the day of ET in the form of

hemoconcentration (RR: 0.44, 95% CI: 0.20–0.97), ascitic fluid collection and ovarian volume

in the control group in comparison with the cabergoline group. Consequently, the

hospitalization rate was lower in the cabergoline group in comparison with the control group,

but this difference was not statistically significant (RR: 0.42, 95% CI: 0.06–3.14) (Table 2).

There was no evidence of a statistically significant difference between the groups as regards

the number of oocytes retrieved (23.4 ± 2.7 vs. 24 ± 2.6), number of MII oocytes (16.4 ± 2.8

vs. 16.8 ± 2.7), or fertilization rate (72% vs. 74%).

68

Figure.1. Flow diagram shows patients enrollment in the study.

Assessed for eligibility (n= 250)

Excluded (n= 50)♦ Declined to participate (n= 50 )

Analysed (n= 100)♦ Excluded from analysis (n=0)

Lost to follow-up (give reasons) (n= 0)Discontinued intervention (n=1) due to nausea & vomiting

Allocated to Cabergoline (n= 100)♦ Received allocated intervention (n= 100 ) ♦ Did not receive allocated intervention (give

reasons) (n= 0)

Lost to follow-up (give reasons) (n=0)

Discontinued intervention (n= 0)

Allocated to control (n= 100)♦ Received allocated intervention (n=100 ) ♦ Did not receive allocated intervention (give

reasons) (n=0)

Analysed (n=100)♦ Excluded from analysis (n=0)

Allocation

Analysis

Follow-Up

Randomized (n= 200)

Enrollment

69

Table I: Demographic criteria of included women in both groups

Cabergoline group (Group I) (n=100) mean± SD

Control group (Group II) (n=100) mean± SD

P- value*

Age (years) 27.6±3.6 27.9±3.8 NS

BMI (Kg/m2) 24.56±2.7 25±3.3 NS

Cause of Infertility (n ;%)

Male factor

Anovulation

Unexplained infertility

Tubal factor

42 (44.2%)

22 (23% )

16 (16.8)

15 (15.7%)

45 (46.8%)

20 (20.8%)

13 (13.5%)

18 (18.7%)

NS

NS

NS

NS

No. women with PCOS (n ;%) 47 (49.5%) 50 (52%) NS

E2 on day of hCG 3882.6 ± 364.5 3953 ± 377 NS

* P value of ≤ 0.05 was considered statistically significant

Table II: Clinical outcomes in cabergoline and control groups

Cabergoline

(Group I)

mean± SD

Control

(Group II)

mean± SD

RR (95% CI)p-value

Severe OHSS (n ;%) 1(10%) 3 (14%) 0.7 (0.08 – 5.92) NS

Moderate OHSS (n ;%) 4(40%) 11(52%) 0.76 (0.32 – 1.81) NS

Mild OHSS (n ;%) 5 (50%) 7 (33%) 1.50( 0.63 to 3.57) NS

Early onset OHSS (n ;%) 0 8 (38%) 0.12 (0.01- 1.86) NS

Late onset OHSS (n ;%) 10 (100%) 13 (61%) 1.56 (1.09 – 2.22) 0.01

ovarian volume (ml) 129.3±70 159.8±56.6 <0.0001

Ascitic fluid (cm) 4.6±1.6 6.7±1.7 <0.0001

OHSS incidence (n ;%) 10 (10 %) 21 (21 % ) 0.5 ( 0.29 – 0.83) 0.035

Haemoconcentration (n; %) (8/100)

(8.4%)

( 18/100)

(18.75% )

0.44 ( 0.20 – 0.97) 0.03

Hospitalization (n; %) 1(10%) 5 (23%) 0.42 (0.06 – 3.14) NS


70

Table III: ovarian stimulation & pregnancy outcomes in cabergoline and control groups

Cabergoline

Group(n=100)

Mean ± SD

Control Group (n=100)

Mean ± SD

RR (95% CI)p-value

No. oocytes retrieved per woman randomized 23.4±2.7 24±2.6 NS

No. MII oocytes per woman randomized 16.4±2.8 16.8 ±2.7 NS

Fertilization rate (%) 72 % 74% NS

Clinical pregnancy rate per woman randomized

42 (42%) 41(41%) 1.02 ( 0.74 – 1.42) NS

Early miscarriage rate per woman randomized

5 (5%) 5 (5%) 1.0 (0.30 – 0.35) NS

Ongoing pregnancy rate per woman randomized

37(37%) 36(36%) 0.90 (0.51 -1.60) NS

Live birth rate per woman randomized 37(37%) 36 1.27(0.68 to 2.35) NS


As regards pregnancy outcomes there was no evidence of a statistically significant difference

between the groups in the clinical pregnancy rate (42% vs. 41%); early miscarriage rate (5%

vs. 5%), ongoing pregnancy rate (37% vs. 36%) and live birth rate (37% vs. 36%). There was

no report of any fetal congenital anomalies in either the cabergoline group or the control

group (Table 3).

Comments

This prospective randomized controlled trial has demonstrated that the use of a small dose of

cabergoline (0.25 mg) in high-risk women reduces the risk of OHSS development.

Cabergoline is a dopamine agonist that prevents phosphorylation of the D2 receptor. We

assumed that 0.25 mg of cabergoline could be safely and effectively reduce the incidence of

OHSS in women undergoing ICSI treatment without harming treated women or their babies.

Although this study has some limitations, owing to the lack of sample size calculation, that

need to be taken into account when considering its generalizability, our data show a

favorable effect of cabergoline in reducing the incidence of OHSS with an absolute risk

reduction of 11%, which means that eleven women out of 100 will not experience OHSS

71

under cabergoline administration that they would have as controls. The corresponding

number needed to treat was 9, which mean nine women must be treated with 0.25 mg

cabergoline for 8 days to prevent one extra OHSS that would have happened without

treatment. As severe OHSS, the clinically most relevant outcome, is rare, the data do not

suggest that cabergoline could reduce the risk of both moderate and severe OHSS. Our

study findings also suggest that the use of cabergoline may not impair implantation and

pregnancy rates, which means that cabergoline might not alter the endometrial angiogenesis

[Alvarez et al., 2007; Salah Edeen et al., 2009], but our study was not powered to detect

such a statistical difference between the groups.

Different studies have evaluated the use of cabergoline as a preventive strategy for OHSS

with a varying dose from 0.5 mg up to 1.0 mg [Ata et al., 2009]. Recently, a systematic

review and meta-analysis of four randomized controlled studies (n = 570 women), including

the present study, comparing cabergoline versus placebo or no treatment for the prevention

of severe OHSS was published. The studies used different regimens, 0.5 mg of cabergoline

for 3 weeks beginning on the day after oocyte retrieval [Alvarez et al., 2007]; 0.5 mg tablet of

cabergoline daily for 8 days [Alvarez et al., 2007]; and 0.5 mg, one tablet on two successive

days, repeated 1 week later, starting from day of HCG injection [Salah Edeen et al., 2009].

There was evidence of a statistically significant reduction in the incidence of OHSS in the

cabergoline group (OR: 0.41, 95% CI: 0.25–0.66) with an absolute risk reduction of 12%

(95% CI: 6.1–18.2%), but there was no statistically significant evidence of a reduction in

severe OHSS (OR: 0.50, 95% CI 0.20–1.26) which agrees with our results [Youssef et al.,

2010]

As regards the effect of cabergoline on endometrial angiogenesis, there was no evidence of

statistically significant differences in live birth rate, ongoing pregnancy rate, clinical

pregnancy rate and miscarriage rate between the groups. In addition, there was no report of

congenital anomalies either in cabergoline group or control group.

Recently, concern was raised about the potential risks of new onset of cardiac valvulopathy

with the use of dopamine agonists, especially cabergoline and pergolide, in patients with

Parkinson’s disease and requiring high doses for long duration [Schade et al., 2007]. Most

studies of dopamine agonist use in prolactinoma, however, where dopamine agonist doses

are 10-fold lower than those employed in Parkinson’s disease, have not observed valvular

abnormalities [Herring et al., 2009; Vallette et al., 2009]. On the other hand, a case of severe

tricuspid regurgitation has been reported in a woman with acromegaly who had been taking

low-dose (0.5 mg/day) cabergoline for one year, and the morphology of the tricuspid valve

was typical of cabergoline related valvulopathy. Thus, it is concluded that cabergoline may

72

not be totally safe even at lower doses, and close echocardiography monitoring is

recommended in patients receiving cabergoline treatment, regardless of the dose level

employed [Izgi et al., 2010; Tan et al., 2010]. For OHSS, however, lower doses are used

over a much shorter duration and that might reduce the risk of cardiac valve disease.

In conclusion, the dopamine agonist, cabergoline, at a low dose (0.25 mg) as a prophylactic

strategy leads to a significantly lower overall OHSS incidence in high-risk patients without

jeopardizing the pregnancy outcomes.

Funding

None.

Acknowledgement

None.

73

References

• Aboulghar M. Symposium: update on prediction and management of OHSS.Prevention of OHSS. Reproductive Biomedicine Online 2009; 19:33–42.

• Al-Inany HG, Youssef MA, Aboulghar M, et al. Gonadotrophin-releasing hormone antagonists for assisted reproductive technology. Cochrane Database of Systematic Reviews 2011; 5:CD001750.

• Alper MM, Smith LP, Sills ES. Ovarian hyperstimulation syndrome: current views on pathophysiology, risk factors, prevention, and management. Journal of Experimental & Clinical Assisted Reproduction 2009; 6:3.

• Alvarez C, Alonso-Muriel I, Garcıá G, et al. Implantation is apparently unaffected by the dopamine agonist cabergoline when administered to prevent ovarian hyperstimulation syndrome in women undergoing assisted reproduction treatment: a pilot study. Human Reproduction 2007; 22:3210–4.

• Alvarez C, Martı´-Bonmatı´ L, Novella-Maestre E, et al. Dopamine agonist cabergoline reduces hemoconcentration and ascites in hyperstimulated women undergoing assisted reproduction. Journal of Clinical Endocrinology and Metabolism 2007; 92:2931–7.

• Ata B, Seyhan A, Orhaner S, Urman B. High dose cabergoline in management of ovarian hyperstimulation syndrome. Fertility and Sterility 2009; 92: 1168–74.

• Busso C, Fernańdez-Sańchez M, Garcıá-Velasco JA, et al. The non-ergot derived dopamine agonist quinagolide in prevention of early ovarian hyperstimulation syndrome in IVF patients: a randomized, double-blind, placebo-controlled trial. Human Reproduction 2010; 25:995–1004.

• Carizza C, Abdelmassih V, Abdelmassih S, et al. Cabergoline reduces the early onset of ovarian hyperstimulation syndrome: a prospective randomized study. Reproductive Biomedicine Online 2008; 17:751–5.

• Edwards RG. IVF, IVM, natural cycle IVF, minimal stimulation. Reproductive Biomedicine Online 2007; 15:106–19.

• Garcia-Velasco JA, Pellicer A. New concepts in the understanding of the ovarian hyperstimulation syndrome. Current Opinion in Obstetrics and Gynecology 2003; 15:251–6.

• Garcia-Velasco JA, Isaza V, Quea G, Pellicer A. Coasting for the prevention of ovarian hyperstimulation syndrome: much ado about nothing? Fertility and Sterility 2006; 85:547–54.

• Garcia-Velasco JA. How to avoid ovarian hyperstimulation syndrome: a newindication for dopamine agonists. Reproductive Biomedicine Online 2009; 18 (Suppl. 2):71–5.

• Golan A, Ron-el R, Herman A, et al. Ovarian hyperstimulation syndrome: an update review. Obstetrical and Gynecological Survey 1989; 44:430–40.

• Gomez R, Gonzalez-Izquierdo M, Zimmermann RC, et al. Low-dose dopamine agonist administration blocks vascular endothelial growth factor (VEGF) - mediated vascular hyperpermeability without altering VEGF receptor 2-dependent luteal

74

angiogenesis in a rat ovarian hyperstimulation model. Endocrinology 2006;147:5400–11

• Go´mez R, Soares SR, Busso C, Garcia-Velasco JA, Simoń C, Pellicer A. Physiology and pathology of ovarian hyperstimulation syndrome. Seminars in Reproductive Medicine 2010; 28:448–57.

• Herring N, Szmigielski C, Becher H, Karavitaki N, Wass JA. Valvular heart disease and the use of cabergoline for the treatment of prolactinoma. Clinical Endocrinology 2009; 70:104–8.

• Izgi C, Feray H, Cevik C, Saltan Y, Mansuroglu D, Nugent K. Severe tricuspid regurgitation in a patient receiving low-dose cabergoline for the treatment of acromegaly. Journal of Heart Valve Disease 2010; 19:797–800.

• Khattab S, Fotouh IA, Mohesn IA, Metwally M, Moaz M. Use of metformin for prevention of ovarian hyperstimulation syndrome: a novel approach. Reproductive Biomedicine Online 2006; 13:194–7.

• Nastri CO, Ferriani RA, Rocha IA, Martins WP. Ovarian hyperstimulation syndrome: pathophysiology and prevention. Journal of Assisted Reproduction and Genetics 2010; 27:121–8.

• Rizk B, Aboulghar M, Smitz J, Ron-El R. The role of vascular endothelial growthfactor and interleukins in the pathogenesis of severe ovarian hyperstimulationsyndrome. Human Reproduction Update 1997; 3:255–66.

• Rollene NL, Amols MH, Hudson SB, Coddington CC. Treatment of ovarian hyperstimulation syndrome using a dopamine agonist and gonadotropin releasing hormone antagonist: a case series. Fertility and Sterility 2009; 92: 1169–77.

• Salah Edeen AMR, Alhelou YM. Can cabergoline prevent ovarian hyperstimulation syndrome in PCO patients undergoing gonadotropin stimulation? Comparative study with prednisolone. Abstracts of the 25th annual meeting of ESHRE, Amsterdam, the Netherlands, 28 June–1 July; 2009.

• Schade R, Andersohn F, Suissa S, Haverkamp W, Garbe E. Dopamine agonists and the risk of cardiac-valve regurgitation. New England Journal of Medicine 2007; 356:29–38.

• Soares SR, Go´mez R, Simoń C, Garcıá-Velasco JA, Pellicer A. Targeting the vascular endothelial growth factor system to prevent ovarian hyperstimulation syndrome. Human Reproduction Update 2008; 14:321–33.

• Spitzer D, Wogatzky J, Murtinger M, Zech MH, Haidbauer R, Zech NH. Dopamine agonist bromocriptine for the prevention of ovarian hyperstimulation syndrome. Fertility and Sterility 2011; 95:2742–4.

• Tan T, Cabrita IZ, Hensman D, et al. Assessment of cardiac valve dysfunction in patients receiving cabergoline treatment for hyperprolactinaemia. Clinical Endocrinology 2010; 73:369–74.

• Vallette S, Serri K, Rivera J, et al. Long-term cabergoline therapy is not associated with valvular heart disease in patients with prolactinomas. Pituitary 2009; 12:153–7.

• Vyjayanthi S, Tang T, Fattah A, Deivanayagam M, Bardis N, Balen AH. Elective cryopreservation of embryos at the pronucleate stage in women at risk of ovarian

75

hyperstimulation syndrome may affect the overall pregnancy rate. Fertility and Sterility 2006; 86:1773–5.

• Youssef MA, van Wely M, Hassan MA, et al. Can dopamine agonists reduce the incidence and severity of OHSS in IVF/ICSI treatment cycles? A systematic review and meta-analysis. Human Reproduction Update 2010; 16: 459–66.

• Youssef MA, Al-Inany HG, Aboulghar M, Mansour R, Abou-Setta AM. Recombinant versus urinary human chorionic gonadotrophin for final oocyte maturation triggering in IVF and ICSI cycles. Cochrane Database of Systematic Reviews 2011; 4:CD003719.

• Youssef MA, Al-Inany HG, Evers JL, Aboulghar M. Intra-venous fluids for the prevention of severe ovarian hyperstimulation syndrome. Cochrane Database of Systematic Reviews 2011; 2:CD001302.

• Youssef MA, van der Veen F, Al-Inany HG, et al. Gonadotropin-releasing hormone agonist versus HCG for oocyte triggering in antagonist assisted reproductive technology cycles. Cochrane Database of Systematic Reviews 2011; 1:CD008046.

76

Chapter 4

Can dopamine agonists reduce the incidence and severity of OHSS in IVF/ICSI treatment cycles? A

systematic review and meta-analysis.

Youssef MA, van Wely M, Hassan MA, Al-Inany HG,

Mochtar M, Khattab S, van der Veen F.

Hum Reprod Update. 2010; 16(5):459-66

77

Abstract

Background: Recently, dopamine agonists were proposed as a prophylactic treatment for

ovarian hyperstimulation syndrome (OHSS) in women at high risk in IVF/ICSI treatment

cycles.

Methods: We conducted a systematic review and meta-analysis of randomized trials

comparing the prophylactic effect of the dopamine agonist, cabergoline, versus no treatment

in IVF/ICSI cycles. Primary outcome was OHSS incidence per randomized woman.

Secondary outcomes were live birth rate, ongoing pregnancy rate, clinical pregnancy rate

and miscarriage rate. Searches (until September 2009) were conducted in MEDLINE,

EMBASE, Science Direct, Cochrane Library and databases of abstracts.

Results: Four randomized trials entailing 570 women were included. There was evidence of

a statistically significant reduction in the incidence of OHSS in the cabergoline group (OR

0.41, 95% CI 0.25–0.66) with an absolute risk reduction of 12% (95% CI 6.1–18.2%), but

there was no statistically significant evidence of a reduction in severe OHSS (OR 0.50, 95%

CI 0.20–1.26). There was no evidence for a difference in clinical pregnancy rate (OR 1.07,

95% CI 0.70–1.62) and miscarriage rate (OR 0.31, 95% CI 0.03–3.07).

Conclusion: Prophylactic treatment with the dopamine agonist, cabergoline, reduces the

incidence, but not the severity of OHSS, without compromising pregnancy outcomes.

78

Introduction

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic, serious and potentially fatal

complication of ovarian stimulation, affecting 1–14% of all IVF/ICSI cycles (Pellicer and

Garcia-Velasco, 2003). OHSS may be associated with massive ovarian enlargement,

ascites, hydrothorax, liver dysfunction and renal failure and can lead to cancellation of an IVF

cycle, prolonged bed rest or hospitalization, all of which have significant emotional, social

and economic consequences (Delvigne et al., 2002; Engmann et al., 2008). Many strategies

have been tried to prevent OHSS, including cycle cancellation, coasting (Garcia-Velasco et

al., 2006), intravenous albumin administration around the time of oocyte retrieval

(Abouelghar et al., 2002, 2009), GnRH agonist as an oocyte trigger in GnRH antagonist

cycles (Kol and Solt, 2008; Youssef et al., 2009), natural-cycle IVF (Edwards, 2007) or in

vitro oocyte maturation (Loutradis et al., 2006). Unfortunately, none of the strategies currently

employed completely prevents OHSS after HCG administration.

OHSS can present in an early form which is related to the ovarian response and exogenous

human chorionic gonadotrophin (HCG) administration, and is detected 3–9 days after HCG

administration, and a late form which is due to endogenous HCG and is diagnosed 10–17

days later (Mathur and Jenkins, 2000). Besides HCG, there are certain vasoactive

substances such as vascular endothelial growth factor (VEGF) that also play a role in the

development of OHSS (Yan et al., 1993; Rizk et al., 1997; Enskog et al., 2001; Soares et al.,

2008).

A potential new strategy to prevent OHSS and reduce the severity is the use of a dopamine

agonist (Papaleo et al., 2001; Knoepfelmacher, 2006). It was observed that the

administration of a dopamine agonist in immature rats at low doses simultaneously with HCG

prevented an increase in vascular permeability and did not affect angiogenesis (Gomez et

al., 2006); the effect was due to the availability of dopamine type 2 receptors (Alvarez et al.,

2007a).

A number of clinical trials have recently tested the clinical usefulness of a dopamine agonist

as a possible way to reduce the occurrence and severity of OHSS (Alvarez et al., 2007a, b;

Papaleo et al., 2001; Manno et al., 2005). The objective of our systematic review and meta-

analysis was to determine whether a dopamine agonist can indeed reduce the occurrence

and severity of OHSS syndrome in high-risk patients undergoing ovarian hyperstimulation in

IVF/ICSI treatment cycles.

79

Methods

Search strategy for identification of studies

The following electronic databases were searched: MEDLINE, EMBASE, Science Direct,

Cochrane Central Register of Controlled Trials (CENTRAL) and Web of Science. National

Research Register (NRR), a register of ongoing trials, and the Medical Research Council’s

Clinical Trials Register A search strategy was carried out based on the following terms:

OHSS, Dopamine agonist, cabergoline, AND ovarian hyperstimulation syndrome chorionic or

OHSS AND IVF/ICSI/ART AND randomized controlled trial(s) OR randomised controlled

trial(s). Furthermore, we examined the reference lists of all known primary studies, review

articles, citation lists of relevant publications and abstracts of major scientific meetings (e.g.

ESHRE and ASRM) and included studies to identify additional relevant citations. Finally, the

review authors sought ongoing and unpublished trials by contacting experts in the field. In

addition, references from all identified articles were checked, and hand searches of the

abstracts from the annual meetings of the American Society for Reproductive Medicine and

the European Society for Human Reproduction and Embryology were performed. If

necessary, additional information was sought from the authors. The search was not restricted

by language. The searches were conducted independently by M.Y, M.H and M.W.

Study selection and data extraction

Studies were selected if the target population was infertile couples, of any cause, having a

high risk of developing OHSS. The therapeutic interventions were dopamine agonist for the

prevention of OHSS in IVF or ICSI treatment. Studies had to be of randomized, controlled

design. The primary outcome measure of interest was the reduction of moderate-to-severe

OHSS incidence per randomized woman. Studies were selected in a two-stage process.

First, the titles and abstracts from the electronic searches were scrutinized by three

reviewers independently (M.A.F.M.Y, M.A.H. and M.W.) and full manuscripts of all citations

that were likely to meet the predefined selection criteria were obtained. Secondly, final

inclusion or exclusion decisions were made on examination of the full manuscripts. Any

disagreements about inclusion were resolved by consensus or arbitration by a third reviewer

(F.V., M.M, S.K. and H.G.A.).

The selected studies were assessed for methodological quality by using the components of

study design that are related to internal validity (Juni et al., 2001). Information on the

adequacy of randomization, concealment and blinding was extracted. When needed, the

reviewers wrote to the authors and obtain extra information and the raw data. From each

80

study, outcome data were extracted in 2 × 2 tables. Data extraction was performed in

duplicate by M.Y., M.H. and M.W.

Definition of outcome measures

The outcomes we planned to assess in our analysis were OHSS incidence, OHSS severity

and onset of OHSS, live birth rate, ongoing pregnancy rate, clinical pregnancy rate and

miscarriage rate. The severity of OHSS in the four studies was determined using: Rizk and

Aboulghar 2003 classification (Carizza et al., 2008), modified Golan et al. 1989 classification

(Alvarez et al., 2007a) and Golan et al. 1989 (Shaltout et al., 2009) and Navot et al.’s

classification (Salah Edeen et al., 2009). The OHSS incidence, live birth rate, ongoing

pregnancy rate, clinical pregnancy rate and miscarriage rate were calculated based on the

number of patients randomized in all studies even if some patients were excluded or dropped

out after randomization.

Statistical analysis

Dichotomous outcomes were expressed as an odds ratio (OR) with 95% CI using a fixed

effects model (Mantel and Haenszel, 1959). For the primary outcome, OHSS incidence, the

absolute risk reduction (ARR) and the number needed to treat (NNT) were also presented.

Heterogeneity of treatment effects was evaluated graphically using forest plots (Lewis and

Clarke, 2001) and statistically using the Breslow and Day X2 test. Subgroup analyses

according to the severity and time of onset of OHSS were performed. All statistical analyses

were performed using RevMan 5.0 (Cochrane Collaboration, Oxford, UK).

Results

The search strategy yielded 17 publications related to the topic. Thirteen publications were

excluded as they did not fulfil the selection criteria (Fig. 1). The excluded trials with the main

reason for exclusion are shown in Table I. The included four trials enrolled, in total, 570

randomized women. Of these, 299 women were randomized to receive dopamine agonist,

and 271 women were randomized to receive placebo or no treatment. The quality and the

main characteristics of the included trials are presented in Table II. The included studies

were similar in design. They were truly randomized studies: two studies used computer-

generated randomization (Alvarez et al., 2007a; Carizza et al., 2008) and two studies used

opaque closed envelops (Shaltout1 et al., 2009; Salah Edeen et al., 2009). Only in one

study, the assessor and participants were blinded (Alvarez et al., 2007a). Participants were

women at high risk of developing OHSS with an indication for assisted reproduction (e.g. IVF

with or without ICSI) undergoing controlled ovarian hyperstimulation using a GnRH agonist

protocol.

81

Figure 1 Flow diagram for meta-analysis. Identification and selection of publications.

Main demographic parameters were compared in the included studies and no statistically

significant differences were found. In two trials, all authors declared no financial support

(Alvarez et al., 2007a; Carizza et al., 2008).

We contacted the authors to get extra information about the methodological quality of the

studies and the outcomes (Alvarez et al., 2007a; Carizza et al., 2008; Salah Edeen et al.,

2009; Shaltout et al., 2009). The studies were generally small and underpowered for the

clinically relevant outcome of OHSS, with sample sizes varying from 82 to 200 patients. One

study included donors (Alvarez et al., 2007a) and the other three studies included patients at

high risk of OHSS. Only two trials were published as full papers (Alvarez et al., 2007a;

Carizza et al., 2008) and the other two trials were abstracts presented at the ESHRE meeting

in Amsterdam (Shaltout et al., 2009; Salah Edeen et al., 2009). Cabergoline was the

dopamine agonist in all trials.

82

Table 1. Excluded publications and the reason of exclusionFerraretti et al.,1992 Non randomised , non-controlled trial

Navot et al.,1992 Review

Robert et al.,1996 Case series

Papaleo et al.2001 Comparative non randomised trial

Parazzini et al.,2002 Case series

Tsunoda et al.,2003 Non controlled trial

Manno et al.,2005 non randomised , non-controlled trial

Alvarez et al.,2007 Retrospective, non-randomized, controlled trial

Soares et al.,2008 Review

Ata B et al.,2009 Case series used high dose of dopamine for management of OHSS

Busso et al.,2009 Review

Rollene et al.,2009 Case series

Garcia-Velasco et al., 2009 Review

OHSS incidence per woman randomized

All trials reported on the OHSS incidence. The actual incidence varied from 12% to 50% in

the control group and from 3% to 10% in the agonist group. Pooling the data resulted in a

significantly lower OHSS incidence in the cabergoline group (OR 0.41; 95% CI 0.25– 0.66)

with an ARR following cabergoline of 12% (95% CI 6.1– 18.2%) assuming an OHSS control

rate of 25%. The corresponding NNT was 9 (95% CI 5.5–16.5). The heterogeneity tests were

non-significant (I2 ¼ 0% and P ¼ 0.74), indicating that there was no statistical inconsistency

between the four trials (Fig. 2).

Severity of OHSS

The severity of OHSS was clearly described in four papers and we could stratify the OHSS

cases into a severe and a moderate group. We subsequently pooled the data in a subgroup

analysis according to the severity of OHSS. The incidence of both severe and moderate

OHSS was 50% lower in the dopamine agonist group. This difference was statistically

83

significant for moderate OHSS (OR 0.38, 95% CI 0.22–0.68). As severe OHSS is more rare,

a statistically significant difference could not be shown (OR 0.50, 95% CI 0.20–1.26) (Fig. 3).

Onset of OHSS

For one paper, we could not extract data on the onset of OHSS as this study was done in

donor patients and the end of study assessment was scheduled 7–10 days after the last

dose of cabergoline or placebo (Alvarez et al., 2007a). For the other three papers, we could

stratify the OHSS cases into an early and a late onset group. We subsequently pooled the

data in a subgroup analysis according to the onset of OHSS. There was a statistically

significant lower incidence of early onset OHSS in the cabergoline group than in the control

group (OR 0.10, 95% CI 0.03–0.33). However, we did not find any evidence of a significant

difference in the incidence of late onset OHSS (OR 0.95, 95% CI 0.49–1.81) (Fig. 4).

Pregnancy outcomes

There was no evidence of a statistically significant difference in live birth rate (1 RCT: 19/100

versus 15/100, OR 1.33, 95% CI 0.63– 2.79) and ongoing pregnancy rate (1 RCT: OR 0.88,

95% CI 0.43 to 1.78) (Shaltout1 et al., 2009). From two studies, data on clinical pregnancy

rates could be extracted (Carizza et al., 2008; Shaltout1 et al., 2009). There was no evidence

of a difference in clinical pregnancy rate between both groups (77/183 versus 73/180, OR

1.07, 95% CI 0.70–1.62; I2 ¼ 0%). Two studies reported the miscarriage rate (Carizza et al.,

2008; Shaltout1 et al., 2009). There was no evidence of statistical difference in miscarriage

rate (2 RCT, 6/183 versus 8/ 183: OR 0.85, 95% CI 0.39–1.86).

Discussion

In this systematic review and meta-analysis of randomized trials, we showed that cabergoline

significantly reduces the chance of developing OHSS in IVF and ICSI cycles. The

corresponding NNT was nine (95% CI 5.5–16.5) with an ARR of 12%, 95% CI 6.1–18.2%

following cabergoline use assuming an OHSS control rate of 25%. This means that you must

treat nine patients with dopamine agonist to prevent one case of OHSS that would have

happened otherwise. Subgroup analyses were underpowered to detect differences as only a

few studies were included in the review

Furthermore, the clinically most relevant outcome, severe OHSS, has a low incidence. To

show a statistical difference in severe OHSS more, preferably larger trials are needed.

However, the data tend to suggest that cabergoline reduces the risk of both moderate and

severe OHSS. There was also no evidence of statistically significant differences in live birth

rate, ongoing pregnancy rate, clinical pregnancy rate and miscarriage rate in both groups.

84

There was clinical heterogeneity between trials in the dose of cabergoline either 0.5 mg oral

or 0.25 mg oral and in the regimens used: (i) 0.5 mg oral cabergoline per day for 3 weeks

beginning on the day after oocyte retrieval (Carriza et al., 2008); (ii) one 0.5 mg tablet of

cabergoline daily for 8 days (Alveizer et al., 2007); (iii) 0.5 mg, one tablet on two successive

days, repeated 1 week later, starting from day of HCG injection (Salah Edeen et al., 2009);

(iv) cabergoline 0.25 mg daily for 8 days (Shaltout et al., 2009). This heterogeneity may

generate misleading results. Only in one study were the outcome assessor and the patients

blinded to the intervention group (Alvarez et al., 2007a), which might be a potential source of

bias that could have yielded exaggerated estimates of the effect of cabergoline. However,

the results were consistent across the trials and the results remained unaltered when a

random-effect meta-analysis was conducted as sensitivity analysis.

Other non-randomized trials have also found that a dopamine agonist could be a useful

treatment of OHSS. One trial showed an improvement in 20 hospitalized patients at risk of

OHSS when starting the evening after oocyte retrieval and in 10 severely hyperstimulated

pregnant women after 24–48 h of cabergoline administration at a dose of 1 mg every 48 h

(Manno et al., 2005). In another nonrandomized trial, docarpamine was used in 27 OHSS

patients and 20 (74.1%) had satisfactory effects on diuresis and recovered from their clinical

symptoms of OHSS (Ferraretti et al., 1992; Tsunoda et al., 2003).

There is concern about the effect of cabergoline on endometrial angiogenesis and its impact

on implantation and miscarriage rates. In addition, there is a lack of reliable evidence on

long-term effects on the babies born and general lack of safety data. In the included studies

in our review, there was no difference in clinical pregnancy rates and miscarriage rates

between the groups which may mean that endometrial angiogenesis is not affected. Also,

two of the included RCTs followed the women up to the end of pregnancy and found no

difference in the live birth rate between both treatment groups (Carizza et al., 2008; Shaltout

et al., 2009; Novella-Maestre et al., 2009). As far as we know, there are three non-

randomized studies that did evaluate the long-term effects of cabergoline. The first was a

case series of 226 pregnancies occurring in 205 women who had been exposed to

cabergoline. Follow-up was available for 204 pregnancies. There were 24 miscarriages and

three induced abortions because of major malformations (one Down syndrome in a 42-year-

old woman, one limb-body wall complex, one hydrocephalus). Two of the 148 single live born

infants had significant malformations: one mega-ureter and one scaphocephaly. The author

concluded that there was no increase in miscarriage rate, that the distribution of birth weights

and sex ratio was within the expected range and that there was no increased rate of

congenital malformations (Robert et al., 1996). The second study collected data on 61

pregnancies in 50 women who had been treated with cabergoline for hyperprolactinaemia.

85

Tabl

e 2.

C

hara

cter

istic

s of

rand

omiz

ed tr

ials

of C

aber

golin

e v

ersu

s pl

aceb

o/or

no

trea

tmen

tTr

ial

Part

icip

ants

In

terv

entio

nsou

tcom

es

Qua

lity

feat

ures

A

lvei

zer 2

007

82 o

ocyt

e do

nors

, pat

ient

s at

risk

of

deve

lopi

ng O

HS

S. R

isk

was

def

ined

by

the

deve

lopm

ent o

f 20–

30

folli

cles

larg

er th

an 1

2 m

m in

di

amet

er a

nd re

triev

al o

f mor

e th

an

20 o

ocyt

es.

Ther

e w

as n

o di

ffere

nce

betw

een

the

subj

ects

in

age,

BM

I, ye

ars

of in

ferti

lity

or c

ause

of

infe

rtilit

y

6 pa

tient

s in

the

stud

y gr

oup

& 7

patie

nts

in th

e co

ntro

l gro

up

excl

uded

afte

r ran

dom

isat

ion

beca

use

< 20

follic

les

retri

eved

. C

oast

ing

was

an

excl

usio

n cr

iterio

n

Stim

ulat

ion:

Lon

g G

nRH

ago

nist

+ 1

50-3

00

IU /d

of F

SH

or H

MG

. Stu

dy g

roup

: 0.5

mg

cabe

rgol

ine

daily

for 8

day

s fro

m th

e da

y of

H

CG

inje

ctio

n. C

ontro

l gro

up: n

o tre

atm

ent

Follo

w u

p: H

aem

ocon

cent

ratio

n, a

scite

s m

onito

red,

ova

rian

volu

me,

eve

ry 4

8 ho

urs

OH

SS

inci

denc

e, e

arly

and

late

Dia

gnos

is o

f se

verit

y: m

odifi

ed G

olan

et a

l., 1

989

clas

sific

atio

n ,w

here

mod

erat

e O

HS

S w

as d

efin

ed w

hen

asci

tes

is d

etec

ted

by

ultra

soun

d w

hile

sev

ere

OH

SS

is

defin

ed w

hen

a c

linic

al s

igns

/sym

ptom

s o

f asc

ites

and/

or h

ydro

thor

ax a

nd b

reat

hing

diff

icul

ties

or if

th

ere

is a

n e

vide

nce

of h

aem

ocon

cent

ratio

n,

coag

ulop

athy

, ren

al o

r hep

atic

func

tion

impa

irmen

t (m

odifi

ed G

olan

et a

l., 1

989

clas

sific

atio

n)

Ran

dom

izat

ion:

C

ompu

ter

gene

rate

dC

once

aled

: Yes

Sam

ple

size

:Yes

Blin

ding

: Dou

ble

blin

ded

ITT:

No

Car

riza

2008

166

patie

nts

for I

VF/

ICS

I, E

2> 4

000

pg/m

l, ba

selin

e ch

arac

teris

tics

wer

e si

mila

r in

both

gro

ups

.Age

: 34.

0 vs

. 33

.6 B

MI 1

.67

vs. 1

.66

, E2:

493

2.6

vs. 4

948.

7 , r

FS

H (7

5 iu

) : 2

8.0

VS

29

.0, A

spira

ted

oocy

tes:

23.

0 vs

. 21

.4

Stim

ulat

ion:

OC

P+

long

GnR

H a

goni

st +

150

-30

0 IU

r FS

H S

tudy

gro

up: 0

.5 m

g ca

berg

olin

e da

ily fo

r 3 w

eeks

from

the

day

afte

r ooc

yte

retri

eval

. Con

trol g

roup

: no

treat

men

t Bot

h gr

oups

: rec

eive

d 20

g ro

utin

e I.V

alb

umin

on

the

day

of o

ocyt

e re

triev

al.

Follo

w u

p: h

aem

atol

ogic

al te

sts

and

ultra

soun

d e

very

48

hour

s

OH

SS

(ear

ly, l

ate)

, im

plan

tatio

n ra

te, c

linic

al

preg

nanc

y ra

te, m

isca

rria

ge ra

te.

Dia

gnos

is o

f se

verit

y : R

izk

and

Abou

lgha

r 200

3

Ran

dom

izat

ion:

C

ompu

ter

gene

rate

dC

once

aled

: Yes

Sam

ple

size

:Yes

Blin

ding

: No

ITT:

Unc

lear

Sala

h Ed

een

2009

125

patie

nts

with

PC

OS

,bas

elin

e ch

arac

teris

tics

wer

e si

mila

r in

both

gr

oups

(dat

a no

t giv

en)

Long

GnR

H a

goni

st p

roto

col +

200

-300

IU r

FSH

. Stu

dy g

roup

: 0.5

mg

cabe

rgol

ine

oral

on

2 su

cces

sive

day

s an

d re

peat

ed a

fter o

ne

wee

k st

artin

g fro

m th

e da

y of

HC

G. C

ontro

l gr

oup:

no

treat

men

t. Fo

llow

up:

5 d

ays

afte

r H

CG

inje

ctio

n fo

r clin

ical

and

son

ogra

phic

as

sess

men

t.

OH

SS

se

vere

OH

SS

is d

efin

ed a

ccor

ding

to N

avot

et a

lcl

assi

ficat

ion

Ran

dom

izat

ion:

C

lose

d en

velo

psC

once

aled

: Unc

lear

Sam

ple

siz

e : N

oB

lindi

ng: N

oIT

T: U

ncle

ar

Shal

tout

200

920

0 w

omen

und

ergo

ing

ICS

I and

at

high

risk

for O

HS

S. O

HS

S ri

sk w

as

defin

ed b

y E

>35

00 p

g/m

l on

HC

G

day

plus

20

folli

cles

.>10

mm

. ba

selin

e ch

arac

teris

tics

wer

e si

mila

r be

twee

n bo

th g

roup

s (D

ata

not

give

n). P

atie

nts

with

E2>

500

0 pg

/ml w

ere

excl

uded

Long

GnR

H a

goni

st p

lus

HM

G p

lus

5000

IU

HC

G.

Stu

dy g

roup

: 0.2

5 m

g ca

berg

olin

e da

ily fo

r 8 d

ays

from

the

day

of H

CG

in

ject

ion.

Con

trol g

roup

: no

treat

men

t. Fo

llow

up

: Hae

moc

once

ntra

tion,

asc

ites,

ova

rian

volu

me

OH

SS

inci

denc

e, s

ever

ity a

nd o

nset

, fer

tiliz

atio

n ra

te, c

linic

al p

regn

ancy

rate

, num

ber o

f ret

rieve

d oo

cyte

s, M

2 nu

mbe

r se

vere

OH

SS

is d

efin

ed a

ccor

ding

to G

olan

et a

l.,

1989

Ran

dom

izat

ion:

C

lose

d en

velo

psC

once

aled

: U

ncle

arS

ampl

e si

ze ;

Unc

lear

Blin

ding

: No

ITT:

Yes

86

Figure 2 Forest plot of ORs and 95% CI of pooled trials comparing dopamine agonist to control for OHSS incidence per randomized woman

Figure 3 Forest plot of ORs and 95% CI of pooled trials comparing dopamine agonist to control according to the severity of OHSS per randomized woman.

.

87

Figure 4 Forest plot of ORs and 95% CI of pooled trials comparing dopamine agonist to control according to the time of onset of OHSS per randomized women.

These pregnancies resulted in 12 (19.7%) early terminations (five induced abortions, six

spontaneous miscarriages, one hydatidiform mole) and 49 (80.3%) live births. In one case,

malformations were suspected on ultrasound at 12 gestational weeks and the pregnancy

was terminated. There was one case of trisomy 18. The frequency of spontaneous and

induced abortions and major congenital malformations was comparable with rates in the

general population (Parazzini et al., 2002). The third study was retrospectively conducted as

a pilot to evaluate the effect of cabergoline treatment on preventing OHSS in 35 women at a

high risk of developing OHSS and who received cabergoline compared with high risk controls

who did not receive cabergoline. Implantation rates were comparable between the groups

(38.6% and 41.4%), and there were no differences in live births per cycle (40% in both

groups). No minor or major malformation had been observed in any of the babies born

(Alvarez et al., 2007b), but the sample size was too small to detect such a rare event. Still

there is a lack of reliable evidence on long-term effects of dopamine agonist on both treated

women and babies born.

Recently, concern was raised about the potential risks of new onset of cardiac valvulopathy

with the use of dopamine agonists, especially cabergoline and pergolide in patients with

Parkinson’s disease and requiring high doses for long duration (Schade et al., 2007;

Zanettini et al., 2007). However, most studies of dopamine agonist use in prolactinoma

where dopamine agonist doses are 10-fold lower than those employed in Parkinson’s

88

disease have not observed valvular abnormalities (Cheung and Heaney, 2009; Herring et al.,

2009). Furthermore, in a randomized trial, the long-term effect of cumulative doses of

cabergoline was studied in patients with prolactinomas. In this trial, no correlation was found

between the presence of significant heart valve regurgitation and cabergoline cumulative

dose, duration of cabergoline treatment, prior use of bromocriptine, age or prolactin levels. It

was concluded that low doses of cabergoline seem to be a safe treatment of

hyperprolactinaemic patients (Vallette et al., 2009). For OHSS, much lower doses are used

over a shorter period of time; hence the risk of cardiac valvulopathy is likely to be negligible.

Finally, it should not go unmentioned that the exact aetiology and pathogenesis of OHSS is

still unclear, and therefore any preventive treatment remains non-specific. Further studies are

needed to establish dose and protocol for OHSS prevention using dopamine agonists. Also,

it would also be important to explore the use of other dopamine agonists.

There are many alternative protocols and medications to treat OHSS. In view of the low

evidence, however, the role of dopamine agonists in the field of OHSS prevention is still

unclear. We conclude that dopamine agonist as a preventive treatment leads to a

significantly lower OHSS incidence in high-risk patients, especially for early onset OHSS

without compromising pregnancy outcomes

Acknowledgements

We want to thank Dr Shaltout, Dr Salah Edeen, Dr Alvarez and Dr Carizza for providing

information regarding methodology and outcome data.

89

References

• Aboulghar M, Evers JH, Al-Inany H. Intravenous albumin for preventing severe ovarian hyperstimulation syndrome: a Cochrane review. Hum Reprod 2002; 17:3027–3032.

• Aboulghar MA, Mansour RT. Ovarian hyperstimulation syndrome: classifications and critical analysis of preventive measures. Hum Reprodu Update 2003; 9:275–289.

• Aboulghar M. Symposium: update on prediction and management of OHSS prevention of OHSS. Reprod Biomed Online 2009; 19:33–42.

• Alvarez C, Marti-Bonmati L, Novella-Maestre E, Sanz R, Gomez R, Fernandez-Sanchez M, Simon C, Pellicer A. Dopamine agonist cabergoline reduces hemoconcentration and ascites in hyperstimulated women undergoing assisted reproduction. J Clin Endocrinol Metab 2007a; 92:2931–2937.

• Alvarez C, Alonso-Muriel I, Garcia G, Crespo J, Bellver J, Simon C, Pellicer A. Implantation is apparently unaffected by the dopamine agonist cabergoline when administered to prevent ovarian hyperstimulation syndrome in women undergoing assisted reproduction treatment: a pilot study. Hum Reprod 2007b; 22:3210–3214.

• Ata B, Seyhan A, Orhaner S, Urman B. High dose cabergoline in management of ovarian hyperstimulation syndrome. Fertil Steril 2009; 92:1168–1164.

• Busso CE, Garcia-Velasco J, Gomez R, Alvarez C, Simon C, Pellicer A. Symposium: update on prediction and management of OHSS prevention of OHSS—dopamine agonists. Reprod Biomed Online 2009; 19:43–51.

• Carizza C, Abdelmassih V, Abdelmassih S, Ravizzini P, Salgueiro L, Salgueiro PT, Jine LT, Nagy P, Abdelmassih R. Cabergoline reduces the early onset of ovarian hyperstimulation syndrome: a prospective randomized study. Reprod Biomed Online 2008; 17:751–755.

• Cheung D, Heaney A. Dopamine agonists and vulvar heart disease. Curr Opin Endocrinol Diabetes Obes 2009; 16:316–320.

• Delvigne A, Rozenberg S. Epidemiology and prevention of ovarian hyperstimulation syndrome (OHSS): a review. Hum Reprod 2002; 8:559–577.

• Garcia-Velasco JA, Pellicer A. New concepts in the understanding of the ovarian hyperstimulation syndrome. Current opinion in obstetrics & Gynecoogy 2003; 15:251–256.

• Garcia-Velasco JA, Isaza V, Quea G, Pellicer A. Coasting for the prevention of ovarian hyperstimulation syndrome: much ado about nothing. Fertil Steril 2006; 85:547–554.

• Edwards RG. IVF, IVM, natural cycle IVF, minimal stimulation. Reprod Biomed Online 2007; 15:106–119.

• Engmann L, DiLuigi A, Schmidt D, Nulsen J, Maier D, Benadiva C. The use of gonadotropin-releasing hormone (GnRH) agonist to induce oocyte maturation after cotreatment with GnRH antagonist in high-risk patients undergoing in vitro fertilization prevents the risk of ovarian hyperstimulation syndrome: a prospective randomized controlled study. Fertil Steril 2008; 89:84–91.

• Enskog A, Nilsson L, Bra¨nnstro¨m M. Plasma levels of free vascular endothelial growth factor(165) (VEGF(165)) are not elevated during gonadotropin stimulation in in vitro

90

fertilization (IVF) patients developing ovarian hyperstimulation syndrome (OHSS): results of a prospective cohort study with matched controls. Eur J Obstet Gynecol Reprod Biol 2001; 96:196–201.

• Ferraretti AP, Gianaroli L, Diotallevi L. Dopamine treatment for severe ovarian hyperstimulation syndrome. Hum Reprod 1992; 7:180–183.

• Garcia-Velasco JA. How to avoid ovarian hyperstimulation syndrome: a new indication for dopamine agonists. Reprod Biomed Online 2009; 18(Suppl. 2):71–75.

• Herring N, Szmigielski C, Becher H, Karavitaki N, Wass JA. Valvular heart disease and the use of cabergoline for the treatment of prolactinoma. Clin Endocr 2009; 70:104–108.

• Gomez R, Gonzalez-Izquierdo M, Zimmermann RC, Novella-Maestre E, Alonso-Muriel I, Sanchez-Criado J, Remohi J, Simon C, Pellicer A. Low-dose dopamine agonist administration blocks vascular endothelial growth factor (VEGF)-mediated vascular hyperpermeability without altering VEGF receptor 2-dependent luteal angiogenesis in a rat ovarian hyperstimulation model. Endocrinology 2006; 147:5400–5411.

• Juni P, Altman DG, Egger M. Systematic reviews in health care-Assessing the quality of controlled clinical trials. British Medical Journal 2001; 323:42–46.

• Knoepfelmacher M, Danilovic DL, Rosa Nasser RH, Mendonca BB. Effectiveness of treating ovarian hyperstimulation syndrome with cabergoline in two patients with gonadotropin-producing pituitary adenomas. Fertil Steril 2006; 86:719.e15–719.e18.

• Kol S, Solt I. GnRH agonist for triggering final oocyte maturation in patients at risk of ovarian hyperstimulation syndrome: still a controversy? J Assist Reprod Genet 2008; 25:63–66.

• Lewis S, Clarke M. Forest plots: trying to see the wood and trees. British Medical Journal 2001; 23:371–371.

• Loutradis D, Kiapekou E, Zapanti E, Antsaklis A. Oocyte maturation in assisted reproductive techniques. Ann N Y Acad Sci 2006; 1092:235–246.

• Manno M, Tomei F, Marchesan E, Adamo V. Cabergoline: a safe, easy, cheap, and effective drug for prevention/treatment of ovarian hyperstimulation syndrome? Eur J Obstet Gynecol Reprod Biol 2005; 122:127–128.

• Manno M, Tomei F, Marchesan E, Adamo V. An important new adaption of a specific drug? Fertil Steril 2007; 88:533.

• Mantel N, Haenszel W. Statistical aspects of the analysis of data from retrospective studies. J Natl Cancer Inst 1959; 22:719–748.

• Mathur RS, Jenkins JM. Is ovarian hyperstimulation syndrome associated with a poor obstetric outcome? BJOG 2000; 107:943–946.

• Navot D, Bergh PA, Laufer N. Ovarian hyperstimulation syndrome in novel reproductive technologies: prevention and treatment. Fertil Steril 1992; 58:249–261.

• Novella-Maestre E, Carda C, Noguera I, Ruiz-Saurı´ A, Garcı´a-Velasco JA, Simo´n C, Pellicer A. Dopamine agonist administration causes a reduction in endometrial implants through modulation of angiogenesis in experimentally induced endometriosis. Hum Reprod 2009; 24:1025–1035.

91

• Papaleo E, Doldi N, De SL, Marelli G, Marsiglio E, Rofena S, Ferrari A. Cabergoline influences ovarian stimulation in hyperprolactinaemic patients with polycystic ovary syndrome. Hum Reprod 2001; 16:2263–2266.

• Parazzini FE, Motta T, Ferrari CL, Colao A, Clavenna A, Rocchi F, Gangi E, Paracchi S, Gasperi M. Pregnancy outcome after cabergoline treatment in early weeks of gestation. Reprod Toxicol 2002; 16:791–793.

• Rizk B, Aboulghar M, Smitz J, Ron-El R. The role of vascular endothelial growth factor and interleukins in the pathogenesis of severe ovarian hyperstimulation syndrome. Hum Reprod Update 1997; 3:255–266.

• Robert E, Musatti L, Piscitelli G. Pregnancy outcome after treatment with the ergot derivative cabergoline. Reprod Toxicol 1996; 10:333–337. Rollene NL, Amols MH, Hudson SB, Coddington CC. Treatment of ovarian hyperstimulation syndrome using a dopamine agonist and gonadotropin releasing hormone antagonist: a case series. Fertil Steril 2009; 92:1169–1167.

• Salah Edeen AMR, Alhelou YM. Can cabergoline prevent ovarian hyperstimulation syndrome in PCO patients undergoing gonadotropin stimulation? Comparative study with prednisolone. Abstracts of the 25th Annual Meeting of ESHRE, Amsterdam, The Netherlands, 28 June–1 July 2009.

• Schade R, Andersohn F, Suissa S, Haverkamp W, Garbe E. Dopamine agonists and the risk of cardiac-valve regurgitation. N Engl J Med 2007; 356:29–38.

• Shaltout A, Shohayeb A, Eid M, Abbas S. Role of cabergoline in preventing ovarian hyperstimlation syndrome in high risk intracytoplasmic sperm injection (ICSI) patients and effect on outcome. Abstracts of the 25th Annual Meeting of ESHRE, Amsterdam, The Netherlands, 28 June–1 July 2009.

• Soares SR, Gomez R, Simon C, Garcia-Velasco JA, Pellicer A. Targeting the vascular endothelial growth factor system to prevent ovarian hyperstimulation syndrome. Hum Reprod Update 2008; 14:321–333.

• Tsunoda T, Shibahara H, Hirano Y, Suzuki T, Fujiwara H, Takamizawa S, Ogawa S, Motoyama M, Suzuki M. Treatment for ovarian hyperstimulation syndrome using an oral dopamine pro drug, docarpamine. Gynecol Endocrinol 2003; 17:281–286.

• Vallette S, Serri K, Rivera J, Santagata P, Delorme S, Garfield N, Kahtani N, Beauregard H, Aris-Jilwan N, Houde G et al. Long-term cabergoline therapy is not associated with valvular heart disease in patients with prolactinomas. Pituitary 2009; 12:153–157.

• Yan Z, Weich HA, Bernart W, Breckwoldt M, Neulen J. Vascular endothelial growth factor (VEGF) messenger ribonucleic acid (mRNA) expression in luteinized human granulosa cells in vitro. J Clin Endocrinol Metab 1993; 77:1723–1725.

• Youssef M, van der veen F, AL-inany H, Griesinger G, Van Wely M. Gonadotropin-releasing hormone agonist versus HCG for oocyte triggering in antagonist ART cycles. A systematic review meta-analysis. Abstracts of the 25th Annual Meeting of ESHRE, Amsterdam, The Netherlands, 28 June–1 July, 2009.

• Zanettini R, Antonini A, Gatto G, Gentile R, Tesei S, Pezzoli G. Valvular heart disease and the use of dopamine agonists for Parkinson’s disease. N Engl J Med 2007; 356:39–46.

92

Chapter 5

Gonadotropin-releasing hormone agonist versus HCG for oocyte triggering in antagonist-assisted reproductive

technology.

Youssef MA, van der Veen F, Al-Inany HG, Mochtar MH,

Griesinger G, Nagi Mohesen M, Aboulfoutouh I, van Wely M.

Cochrane Database Syst Rev. 2014 Oct 31; 10:CD008046

93

Abstract

Background: Human chorionic gonadotropin (HCG) is routinely used for final oocyte

maturation triggering in in vitro fertilisation (IVF)/ intracytoplasmic sperm injection (ICSI)

cycles, but the use of HCG for this purpose may have drawbacks. Gonadotropin-releasing

hormone (GnRH) agonists present an alternative to HCG in controlled ovarian

hyperstimulation (COH) treatment regimens in which the cycle has been down-regulated with

a GnRH antagonist. This is an update of a review first published in 2010.

Objectives: To evaluate the effectiveness and safety of GnRH agonists in comparison with

HCG for triggering final oocyte maturation in IVF and ICSI for women undergoing COH in a

GnRH antagonist protocol.

Search methods: We searched databases including the Menstrual Disorders and Subfertility

Group (MDSG) Specialised Register of Controlled Trials, the Cochrane Central Register of

Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, the Cumulative Index to

Nursing and Allied Health Literature (CINAHL) and trial registers for published and

unpublished articles (in any language) on randomised controlled trials (RCTs) of

gonadotropin-releasing hormone agonists versus HCG for oocyte triggering in GnRH

antagonist IVF/ICSI treatment cycles. The search is current to 8 September 2014.

Selection criteria: RCTs that compared the clinical outcomes of GnRH agonist triggers

versus HCG for final oocyte maturation triggering in women undergoing GnRH antagonist

IVF/ICSI treatment cycles were included.

Data collection and analysis: Two or more review authors independently selected studies,

extracted data and assessed study risk of bias. Treatment effects were summarised using a

fixed-effect model, and subgroup analyses were conducted to explore potential sources of

heterogeneity. Treatment effects were expressed as mean differences (MDs) for continuous

outcomes and as odds ratios (ORs) for dichotomous outcomes, together with 95%

confidence intervals (CIs). Primary outcomes were live birth and rate of ovarian

hyperstimulation syndrome (OHSS) per women randomised. Grades of Recommendation,

Assessment, and Development and Evaluation (GRADE) methods were used to assess the

quality of the evidence for each comparison.

Main results: We included 17 RCTs (n = 1847), of which 13 studies assessed fresh

autologous cycles and four studies assessed donor-recipient cycles. In fresh autologous

cycles, GnRH agonists were associated with a lower live birth rate than was seen with HCG

(OR 0.47, 95% CI0.31 to 0.70; five RCTs, 532 women, I2 = 56%, moderate-quality

evidence). This suggests that for a woman with a 31% chance of achieving live birth with the

use of HCG, the chance of a live birth with the use of a GnRH agonist would be between

12% and 24%. In women undergoing fresh autologous cycles, GnRH agonists were

94

associated with a lower incidence of mild, moderate or severe OHSS than was HCG (OR

0.15, 95% CI 0.05 to 0.47; eight RCTs, 989 women, I² = 42%, moderate-quality evidence).

This suggests that for a woman with a 5% risk of mild, moderate or severe OHSS with the

use of HCG, the risk of OHSS with the use of a GnRH agonist would be between nil and 2%.

In women undergoing fresh autologous cycles, GnRH agonists were associated with a lower

ongoing pregnancy rate than was seen with HCG (OR 0.70, 95% CI 0.54 to 0.91; 11 studies,

1198 women, I2 = 59%, low-quality evidence) and a higher early miscarriage rate (OR 1.74,

95% CI 1.10 to 2.75; 11 RCTs, 1198 women, I² = 1%, moderate-quality evidence). However,

the effect was dependent on the type of luteal phase support provided (with or without

luteinising hormone (LH) activity); the higher rate of pregnancies in the HCG group applied

only to the group that received luteal phase support without LH activity (OR 0.36, 95% CI

0.21 to 0.62; I2 = 73%, five RCTs, 370 women). No evidence was found of a difference

between groups in risk of multiple pregnancy (OR 3.00, 95% CI 0.30 to 30.47; two RCTs, 62

women, I2 = 0%, low-quality evidence). In women with donor-recipient cycles, no evidence

suggested a difference between groups in live birth rate (OR 0.92, 95% CI 0.53 to 1.61; one

RCT, 212 women) or ongoing pregnancy rate (OR 0.88, 95% CI 0.58 to 1.32; three RCTs,

372 women, I² = 0%). We found evidence of a lower incidence of OHSS in the GnRH

agonist group than in the HCG group (OR 0.05, 95% CI 0.01 to 0.28; three RCTs, 374

women, I² = 0%). The main limitation in the quality of the evidence was risk of bias

associated with poor reporting of methods in the included studies.

Authors’ conclusions: Final oocyte maturation triggering with GnRH agonist instead of

HCG in fresh autologous GnRH antagonist IVF/ICSI treatment cycles prevents OHSS to the

detriment of the live birth rate. In donor-recipient cycles, use of GnRH agonists instead of

HCG resulted in a lower incidence of OHSS, with no evidence of a difference in live birth

rate. Evidence suggests that GnRH agonist as a final oocyte maturation trigger in fresh

autologous cycles is associated with a lower live birth rate, a lower ongoing pregnancy rate

(pregnancy beyond 12 weeks) and a higher rate of early miscarriage (less than 12 weeks).

GnRH agonist as an oocyte maturation trigger could be useful for women who choose to

avoid fresh transfers (for whatever reason), women who donate oocytes to recipients or

women who wish to freeze their eggs for later use in the context of fertility preservation.

95

Introduction After oocyte growth is stimulated by gonadotropins, the next step in in vitro fertilisation (IVF)

and intracytoplasmic sperm injection (ICSI) treatment consists of triggering the oocytes to go

through the last stage of maturation, so that they can be retrieved and fertilised. This final

oocyte maturation is usually triggered by human chorionic gonadotropin (HCG), but use of

HCG for this purpose may have drawbacks. Some studies have suggested a negative impact

of HCG on endometrial receptivity (Simon 1995; Forman 1998; Simon 1998) and embryo

quality (Valbuena 2001; Tavaniotou 2002). In addition, the sustained luteotrophic effect of

HCG is associated with increased chances of ovarian hyperstimulation syndrome (OHSS),

which is an iatrogenic complication of assisted reproductive technology (ART). OHSS may

be associated with massive ovarian enlargement, ascites, hydrothorax, liver dysfunction and

renal failure. It can lead to cancellation of an IVF cycle and the need for prolonged bed rest

or hospitalisation, which may have a significant emotional, social and economic impact or-in

its most severe form-may even result in mortality (Delvigne 2003).

Gonadotropin-releasing hormone (GnRH) agonists present an alternative to HCG for

triggering endogenous luteinising hormone (LH) release (Gonen 1990; Olivennes 1996;

Olivennes 2001; Tay2002). Use of GnRH agonist triggering is applicable only in IVF with

controlled ovarian hyperstimulation (COH) treatment regimens in which the cycle has been

down-regulated by a GnRH antagonist. Because of the specific mode of action of the

antagonist, the pituitary remains responsive to a GnRH agonist, provided that the GnRH

antagonist treatment utilised standard doses (Felberbaum 1995; Orvieto 2006).

A midcycle single bolus of GnRH agonist may be injected subcutaneously (0.2 to 0.5 mg of

triptorelin, leuprorelin or buserelin) (Itskovitz-Eldor 2000; Humaidan 2005) or administered

intranasally (200 μg buserelin) (Pirard 2006). A single injection of a GnRH agonist results in

an acute release of LH and follicle-stimulating hormone (FSH)-the so-called flare-up. Serum

LH and FSH levels rise after four hours and 12 hours, respectively, and are elevated for 24 to

36 hours. The amplitude of the surges is similar to that seen in the normal menstrual cycle,

but, in contrast to the natural cycle, the LH surge consists of two phases: a short ascending

limb (> 4 hours) and a long descending limb (> 20 hours). This has no bearing on luteal

phase steroid levels, which are qualitatively similar to those observed in the natural cycle

(Segal 1992; Itskovitz-Eldor 2000; Fauser 2002; Nevo 2003; Kol 2004).

Consequently, oocyte maturation triggering with GnRH agonists may provide several

advantages over that achieved with HCG. First, GnRH agonists reduce the risk of OHSS due

96

to quick and irreversible luteolysis (Kol 2004). Second, a more physiological LH and FSH

surge is induced by the agonists, which may result in better oocyte and embryo quality

(Humaidan 2005). Third, GnRH agonists may improve endometrial quality as a result of the

lower luteal phase steroid levels (Forman 1998; Simon 1998).

This is an update of a review first published in 2010 (Youssef 2010). HCG is the standard

medication for final oocyte maturation triggering. More recently, GnRH agonists have been

proposed, especially as they may prevent OHSS to a large extent. Summarising the

available evidence shows what is known about the effectiveness and safety of GnRH

agonists in comparison with HCG and hence will help fertility experts and women to make

informed decisions on final oocyte maturation triggering by GnRH antagonists in IVF/ICSI

treatment cycles.

Objectives: To evaluate the effectiveness and safety of GnRH agonists in comparison with

HCG for triggering final oocyte maturation in IVF and ICSI for women undergoing COH in a

GnRH antagonist protocol.

MethodsCriteria for considering studies for this reviewTypes of studies: Only published and unpublished randomised controlled trials (RCTs) were

included in the review. Non-randomised studies (e.g. studies with evidence of inadequate

sequence generation such as alternate days and participant numbers), as they are

associated with high risk of bias, were excluded from the review. Cross-over trials were

excluded, as the design is not valid in this context.

Types of participantsInclusion criteria: Subfertile couples undergoing IVF or ICSI for therapeutic reasons or for

oocyte donation and randomly assigned to receive a GnRH agonist or HCG for final oocyte

maturation triggering.

Exclusion criteria: Women who were not undergoing IVF or ICSI (i.e. those undergoing

intrauterine insemination (IUI).

Types of interventions: GnRH agonists in comparison with HCG for final oocyte maturation

triggering in GnRH antagonist-controlled hyperstimulation cycles, IVF or ICSI followed by

embryo transfer (ET) with or without luteal phase support, in autologous or donor cycles.

Types of outcome measuresPrimary outcomes: Live birth rate (LBR) per woman randomised: live birth defined as

delivery of a live fetus after 20 completed weeks of gestation. Incidence of OHSS per

woman randomised (mild, moderate or severe): detected by clinical, laboratory or imaging

grading of OHSS.

97

Secondary outcomes: Ongoing pregnancy rate (OPR) per woman randomised: ongoing

pregnancy defined as pregnancy beyond 12 weeks. Clinical pregnancy rate (CPR) per

woman randomised: clinical pregnancy defined as presence of a fetal heart rate with

transvaginal ultrasound. Early miscarriage rate per woman randomised. Multiple pregnancy

rates per woman randomised.

Search methods for identification of studies: All published and unpublished RCTs of

GnRH agonists versus HCG for final oocyte maturation triggering were sought, without

language restriction and in consultation with the Menstrual Disorders and Subfertility Group

(MDSG) Trials Search Co-coordinator, using the following search strategy.

Electronic searches2014 updateWe searched the following electronic databases, trial registers and websites to 8 September

2014: the MDSG Specialised Register of Controlled Trials, the Cochrane Central Register of

Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO and the Cumulative Index to

Nursing and Allied Health Literature (CINAHL). Other electronic sources of trials included the

following.

Trial registers for ongoing and registered trials: http:// www.controlled-trials.com,

http://clinicaltrials.gov/ct2/home, http://www.who.int/trialsearch/Default.aspx.

Citation indexes: http://scientific.thomson.com/products/ sci/ Conference abstracts.

Conference abstracts in the Web of Knowledge: http:// www.wokinfo.com

Latin American and Caribbean Health Science Information Database (LILACS) database, for

trials from the Portuguese and Spanish-speaking world: http://bases.bireme.br/cgi -bin/

wxislind.exe/iah/online/?IsisScript=iah/i ah.xis&base=LILACS& lang=i&form=F.

PubMed: www.ncbi.nlm.nih.gov/pubmed/.

Open System for Information on Grey Literature in Europe (OpenSIGLE) database

(http://opensigle.inist.fr/) and Google for grey literature.

MEDLINE and EMBASE search strategies use different filters for identifying randomised

trials. The MEDLINE search was combined with the Cochrane highly sensitive search

strategy for identifying randomised trials, which appears in the Cochrane Handbook for

Systematic Reviews of Interventions (Version 5.0.1, Chapter 6, 6.4.11). EMBASE and

CINAHL searches were combined with trial filters developed by the Scottish Intercollegiate

Guidelines Network (SIGN) (www.sign.ac.uk/methodology/filters. html#random).

Searching other resources: Reference lists of relevant clinical practice guidelines, review

articles and studies. Letters seeking information about unpublished or incomplete RCTs sent

to investigators known to be involved in previous studies.

98

Data collection and analysisSelection of studies: After an initial screen of titles and abstracts retrieved by the search,

conducted by MAFMY and MVW, the full texts of all potentially eligible studies were

retrieved. These full-text articles were examined for compliance with the inclusion criteria,

and review authors selected studies eligible for inclusion in the review. We corresponded

with study investigators as required to clarify study eligibility. The selection process was

documented on a Preferred Reporting Items for Systematic Reviews and Meta- Analyses

(PRISMA) flow chart (Figure 1).Data extraction and management: Two review authors independently extracted data from

eligible studies using a standard data extraction form that they designed and pilot-tested.

Disagreements were resolved by discussion or by consultation with a third review author.

Extracted data included study characteristics and outcome data. Data entry was carried out

by the same two review authors. Studies were analysed for the following quality criteria and

methodological details.

Trial characteristicsStudy design: Method of randomisation; multi-centre or single-centre design; presence or

absence of blinding to treatment allocation; number of participants randomised, excluded or

lost to follow-up, presence of intention-to-treat (ITT) analysis, and presence of a power

calculation.

Characteristics of study participants

• Subfertile women undergoing IVF/ICSI treatment cycles.

• At high or low risk to develop OHSS.

Interventions used

• Types of ovarian hyperstimulation protocols used.

• Types of final oocyte maturation triggering used: route of administration, duration and

dose.

• Types of luteal phase support provided: dose, duration and route of administration.

Outcomes

• LBR.

• Incidence of OHSS.

• Ongoing pregnancy rate.

• Clinical pregnancy rate.

• Miscarriage rate.

• Multiple pregnancy rate.

Assessment of risk of bias in included studies

99

Two review authors independently assessed the included studies for risk of bias using the

risk of bias assessment tool of The Cochrane Collaboration (Higgins 2011) to assess

allocation (random sequence generation and allocation concealment); blinding of

participants, personnel and outcome assessors; incomplete outcome data; selective

reporting; and other bias. Disagreements were resolved by discussion or by consultation with

a third review author.

RandomisationRandomisation was considered adequate if any random method of allocation was described

and was verifiable, that is, using a computerised random number generator; or referring to a

number table.

Concealment of allocation (selection bias)This was considered adequate if a third-party system; serially numbered sealed, opaque

envelopes; or a similar system was described. Concealment was stated as ’unclear’ if no

information was available pertaining to allocation concealment.

Blinding of participants and personnel (performance bias)This was examined with regard to likelihood of bias influencing primary outcomes. We

considered it unlikely that blinding would influence findings for live birth, but likely that

blinding could influence findings for OHSS, so unblended studies were rated as having high

risk of bias for this outcome.

Blinding of outcome assessors (detection bias)This was examined with regard to likelihood of bias influencing primary outcomes. We

considered it unlikely that blinding would influence findings for live birth, but likely that

blinding could influence findings for OHSS, so unblended studies were rated as having high

risk of bias for this outcome.

Incomplete outcome dataLow risk of bias was allocated if no outcome data were missing, or if missing outcome data

were balanced in numbers across intervention groups with similar reasons provided for

missing data across groups.

Selective outcome reportingLow risk of bias was allocated if all of a study’s primary, secondary and additional outcomes

of interest in the review were reported in a prespecified way; when fewer outcome measures

were reported than planned, this was considered to be a source of bias.

Other potential sources of biasWe considered other potential forms of bias (e.g. baseline imbalance of groups, premature

discontinuation of study).

100

Measures of treatment effect: For dichotomous data (e.g. live birth rates), the numbers of

events in control and intervention groups of each study were used to calculate odds ratios

(ORs) with 95% confidence intervals (CIs) for each individual trial.

Unit of analysis issues: The primary analysis was per woman randomised (e.g. live birth

rate or miscarriage rate per woman randomised, defined as the number of women achieving

a live birth divided by the number of women treated). Data per cycle were not included in the

analysis.

Dealing with missing data: When possible, data were extracted to allow for an ITT

analysis, defined as including all randomised participants in the denominator. When

appropriate, study authors were contacted to provide further information or missing data.

Data obtained in this manner were included in our analyses. Women lost to follow-up were

assumed to be not pregnant.

Assessment of heterogeneity: We considered whether clinical and methodological


clinically meaningful summary. We assessed statistical heterogeneity by the measure of the

I2 statistic. An I2 measurement greater than 50% was taken to indicate substantial

heterogeneity (Higgins 2011). We tested the effect of using a random-effects model when

heterogeneity was substantial.


publication bias and other reporting biases, we aimed to minimise their potential impact by

ensuring a comprehensive search for eligible studies and by being alert for duplication of

data. If 10 or more studies were included in an analysis, we planned to use a funnel plot to

explore the possibility of small-study effects (a tendency for estimates of the intervention

effect to be more beneficial in smaller studies).

Data synthesis: Data from primary studies were combined using the fixed-effect model in

the following comparisons.

GnRH agonist versus HCG in fresh autologous cycles.

GnRH agonist versus HCG in donor-recipient cycles.

An increase in the odds of a particular outcome, which may be beneficial (e.g. live birth) or

detrimental (e.g. OHSS, miscarriage), was displayed graphically in the meta-analyses to

the right of the centre-line (i.e. in favour of GnRH agonist), and a decrease in the odds of an

outcome to the left of the centre-line (i.e. in favour of HCG).For the meta-analysis, the

number of women experiencing the event in each group of the trial was recorded. Meta-

analysis of binary data was performed using the Mantel-Haenszel method with a fixed-effect

model, and the OR and the 95% CI were calculated using RevMan 5 software. We

performed a separate analysis for oocyte donor recipient cycles.

101

Subgroup analysis and investigation of heterogeneity: We considered clinical and

methodological differences between studies that might account for any heterogeneity. When

data were available, we conducted subgroup analyses to determine separate evidence within

the following subgroups in studies of autologous cycles.

Type of luteal phase support (for the outcomes of live birth, OHSS and ongoing pregnancy)

• Luteal phase support with LH activity (single or two doses of HCG, rec LH and

repeated GnRH doses).

• Luteal phase support without LH activity (progesterone only or progesterone plus

oestradiol).

Risk of OHSS (for the outcome of OHSS): Studies of women with low OHSS risk: Low risk

was defined as studies excluding women with polycystic ovary syndrome (PCOS) or women

with high numbers of ovarian follicles (≥ 14 follicles) ≥ 11 mm in diameter.

Studies of women with high OHSS risk: High risk was defined as studies including women

with PCOS or women with high numbers of ovarian follicles (≥ 14 follicles) ≥ 11 mm in

diameter.

Sensitivity analysis: We conducted sensitivity analyses for the primary outcomes to

determine whether the conclusions were robust to arbitrary decisions made regarding study

eligibility and analysis. These analyses included consideration of whether the review

conclusions would have differed if:

We had used a random-effects model for the primary outcomes;

We had reported risk ratios rather than odds ratios; or

We had included only moderate or severe OHSS as an outcome (not including mild OHSS).

ResultsDescription of studiesResults of the search: In searches to date (2011 and 2014), a total of 264 references were

identified. Most references identified by the search were excluded at the first screening step,

as they were clearly irrelevant (n = 160). The most frequent reasons for exclusion were the

following: The article was a review or a commentary/editorial, or the study was clearly of a

non-randomised design or reported comparisons of no interest (n = 87); 17 RCTs fulfilled the

inclusion criteria (Figure 1).

Included studiesDesign: Seventeen RCTs, 13 in fresh autologous cycles and four in donor-recipient cycles,

including 1847 randomly assigned women, met the inclusion criteria and were fully reviewed.

Randomisation was done as soon as oocyte maturation triggering was planned in all except

one trial. In this trial, randomisation was timed to occur at the beginning of stimulation

102

(Kolibianakis 2005). Three abstracts (Segal 1992; Ossina 2004; Pe a 2007) were published

in conference proceedings. As it was not possible to obtain further information from the

authors of these abstracts, they were excluded from the quantitative analysis.

Ten studies were randomised controlled single-centre studies (Segal 1992; Acevedo 2006;

Babayof 2006; Humaidan 2006; Pirard 2006; Pe a 2007; Engmann 2008; Galindo 2009;

Melo 2009; Papanikolaou 2010). Three studies were two-centre studies (Beckers 2003;

Humaidan 2005; Kolibianakis 2005), one was a three-centre study (Humaidan 2010), one

was a four centre study (Humaidan 2013) and two studies were six-centre studies (Fauser

2002; Ossina 2004).

Nine studies reported sample size calculations for the primary outcome (Beckers 2003;

Humaidan 2005; Kolibianakis 2005; Babayof 2006; Engmann 2008; Galindo 2009; Melo

2009; Humaidan 2010; Humaidan 2013). No sample size calculation was performed in three

studies (Fauser 2002; Acevedo 2006; Pirard 2006); in five studies, this information was not

provided (Segal 1992; Ossina 2004; Humaidan 2006; Pe a 2007; Papanikolaou 2010).

Three studies failed to achieve the intended sample size (Humaidan 2005; Kolibianakis

2005; Humaidan 2013). Nine studies recruited only a small number of women (Fauser 2002,

n= 57; Beckers 2003, n = 40; Humaidan 2005, n = 45; Acevedo 2006, n = 60; Babayof 2006,

= 28; Pirard 2006, n = 30; Engmann 2008, n= 66; Melo 2009, n = 100; Papanikolaou 2010; n

= 39).

Fourteen RCTs were published as full-text articles (Fauser 2002; Beckers 2003; Humaidan

2005; Kolibianakis 2005; Acevedo 2006; Babayof 2006; Humaidan 2006; Pirard 2006;

Engmann 2008; Galindo 2009; Melo 2009; Humaidan 2010; Papanikolaou 2010; Humaidan

2013) and three as abstracts (Segal 1992; Ossina 2004; Pe a 2007) in conference

proceedings. Source of funding (Lundh 2012): Four studies (28%) reported that they

received industry funding (Beckers 2003; Engmann 2008; Papanikolaou 2010; Humaidan

2013).

Participants: Analysed studies (14/17) included 791 women in the intervention groups and

779 in the control groups. All were women with subfertility from 18 to 40 years of age. All

participants were undergoing IVF/ICSI treatment cycles followed by fresh ET in autologous or

donor cycles. • The number of randomly assigned participants ranged from 23 (Pirard 2006)

to 302 (Humaidan 2010), including both GnRH agonist and HCG groups. • Baseline

characteristics were comparable between groups (Characteristics of included studies). Ten

studies included women at low risk of developing OHSS (Fauser 2002; Beckers 2003;

Humaidan 2005; Kolibianakis 2005; Acevedo 2006; Humaidan 2006; Galindo 2009; Melo

2009; Humaidan 2010; Papanikolaou 2010), and only three studies randomised women with

103

PCOS or with retrieved oocytes with more than 14 follicles (Babayof 2006; Engmann 2008;

Humaidan 2013). Risk of OHSS was reported unclearly in four studies (Segal 1992; Ossina

2004; Pirard 2006; Pe a 2007).

Figure.1 PRISMA study flow diagram

104

Intervention: All included studies compared GnRH agonist versus HCG for final oocyte

maturation triggering in GnRH antagonist down-regulated IVF and ICSI cycles.

Five studies used 250 μg of recombinant HCG (rHCG) for final oocyte maturation triggering

in the control group (Acevedo 2006; Babayof 2006; Galindo 2009; Melo 2009; Papanikolaou

2010). A three-arm study compared LH versus rHCG versus GnRH (Beckers 2003). Other

included studies used 10,000 IU of urinary HCG for final oocyte maturation triggering, except

one (Engmann 2008), which used a dose ranging from 3300 to 10,000 IU, depending on

follicular response.

Luteal phase support: Five studies used progesterone (P) plus oestradiol (E2) in fresh

autologous cycles (Kolibianakis 2005; Humaidan 2005; Babayof 2006; Humaidan 2006;

Engmann 2008) and one study in donor-recipient cycles (Acevedo 2006). Two studies used

the combination of P + E2 + single dose of 1500 IU hCG (Humaidan 2010) or two doses of

1500 IU HCG (Humaidan 2013); one study used P only in fresh autologous cycles (Fauser

2002) and two studies in donor recipient cycles (Galindo 2009; Melo 2009); one study used

the combination of P + six doses of recLH (Papanikolaou 2010); one study used repeated

administration of GnRH agonist (Pirard 2006); and one study provided no luteal phase

support (Beckers 2003).

Outcomes: Five studies reported live birth rate in fresh autologous cycles (Humaidan 2005;

Babayof 2006; Humaidan 2006; Humaidan 2010; Papanikolaou 2010) and one study in

donor recipient cycles (Galindo 2009). Eight studies reported OHSS incidence in fresh

autologous cycles (Kolibianakis 2005; Babayof 2006; Humaidan 2006; Pirard 2006;

Engmann 2008; Humaidan 2010; Papanikolaou 2010; Humaidan 2013) and three studies in

donor-recipient cycles (Acevedo 2006; Galindo 2009; Melo 2009).

All included studies reported ongoing pregnancy rate, clinical pregnancy rate and early

miscarriage rate in both groups. Multiple pregnancy rate was reported in all donor-recipient

cycles and in two studies in fresh autologous cycles (Babayof 2006; Papanikolaou 2010).

Three studies were published as abstracts with no details on outcome measures (Segal

1992; Ossina 2004; Pe a 2007); therefore they were included only in the qualitative research-

not in the meta-analysis.

Excluded studiesIn searches to date (2011 and 2014), a total of 87 studies were excluded.

Risk of bias in included studiesAllocation; Thirteen studies were rated as having low risk of bias related to sequence

generation, and four were rated as having unclear risk of bias in this domain. Six studies

were rated as having low risk of bias related to allocation concealment, and nine were rated

as having unclear risk of this bias. In two trials, the allocation was not adequately concealed;

these studies were rated as having high risk of bias (Kolibianakis 2005; Acevedo 2006).

105

Blinding: One study clearly reported blinding of assessors (Melo 2009) and was deemed to

be at low risk of bias related to blinding. Six studies did not clearly report on blinding and

were rated as having unclear risk of bias related to assessment of OHSS. Ten reported lack

of blinding and were rated as having high risk of bias related to assessment of OHSS.

Incomplete outcome data: Fourteen studies were rated as having low risk of attrition bias.

Three were rated as having unclear risk of bias in this domain.

Intention-to-treat analysis: We contacted the following investigators of individual studies

via email to ask for additional information, so we could perform analyses on an ITT basis

(Fauser 2002; Humaidan 2005; Acevedo 2006; Humaidan 2006; Humaidan 2010). We could

not identify contact details for the authors of two abstracts (Ossina 2004; Pe a 2007);

therefore we excluded these studies from analysis on the basis of missing relevant data.

Only five studies performed an ITT analysis (Humaidan 2006; Galindo 2009; Humaidan

2010; Papanikolaou 2010; Humaidan 2013).

In seven studies, no ITT analysis was performed (Fauser 2002; Beckers 2003; Humaidan

2005; Kolibianakis 2005; Acevedo 2006; Pirard 2006; Engmann 2008), and it was unclear

whether ITT was used in two studies (Babayof 2006; Melo 2009). However, for all of these

studies, the number of women randomised was known; therefore the ITT data could be

imputed.

Selective reporting: Six studies were rated as having low risk of selective reporting bias; 11

were rated as having unclear risk of bias in this domain, in most cases because live birth

and/or OHSS was not reported.

Other potential sources of bias: For eight studies, no additional potential sources of bias

were noted. Four studies were rated as having unclear risk of other bias because they were

reported only as abstracts and provided insufficient details on methods.

Five studies were deemed at high risk of other potential bias. All of these studies were

prematurely discontinued. In one case (Kolibianakis 2005), study discontinuation was

triggered by preplanned stopping rules. In other cases (Beckers 2003; Humaidan 2005;

Pirard 2006), the interim analysis was unplanned and/or stopping rules were unclear. Three

of these studies were stopped prematurely as the result of a significantly lower pregnancy

rate in the GnRH agonist triggering group, and in one trial with six arms, two arms were

stopped prematurely for the same reason (Pirard 2006). One study was stopped prematurely

before the estimated sample size had been obtained as a result of the death of one of the

local principal investigators and job rotations among other investigators (Humaidan 2013).

106

Effects of interventionsPrimary outcomes1.1 Live birth rate per woman randomised1.1.1 Fresh autologous cycles; GnRH agonist trigger was associated with a lower live birth

rate than was seen with HCG (OR 0.47, 95% CI 0.31 to 0.70; five RCTs, 532 women, I² =

56%, moderate-quality evidence). This means that for a woman with a 31% chance of

achieving live birth with the use of HCG, the chance of a live birth with the use of a GnRh

agonist will be between 12% and 24%. Use of a random effects model did not substantially

affect the results (OR 0.38, 95% CI 0.17 to 0.89), nor did use of risk ratios have a substantial

effect. Statistical heterogeneity for this outcome was moderate. The live birth rate varied from

15% to 53% in the HCG group and from 5% to 24% in the agonist group. (Figure 2)

1.1.2 Donor-recipient cycles: No evidence of a difference in live birth rate was noted

between GnRH agonist and HCG groups in donor-recipient cycles (OR 0.92, 95% CI 0.53 to

1.61; one RCT, 212 women)

1.2 Live birth rate in autologous cycles: subgroup analysis on luteal support approachThe subgroup analysis based on luteal phase support methods used in the included studies

revealed differences in live birth rates between trials that used luteal phase support with LH

activity and trials that used luteal phase support without LH activity. Both groups showed

evidence of differences in live birth rate in favor of HCG, but this difference was significantly

greater in studies that used luteal support without LH activity (studies with luteal phase

support with LH activity: OR 0.63, 95% CI 0.40 to 0.98; three RCTs, 382 women, I2 = 0%;

studies with luteal phase support without LH activity: OR 0.13, 95% CI 0.04 to 0.39; two

RCTS, 150 women, I2 = 73%; test for subgroup differences: Chi² = 6.65, df = 1 (P value

0.010), I² = 85.0%).

1.3 Ovarian hyperstimulation syndrome (OHSS)1.3.1 Fresh autologous cycles: GnRH agonist was associated with lower risk of OHSS

(mild, moderate or severe) than was seen with HCG (OR 0.15, 95% CI 0.05 to 0.47; eight

RCTs, 989 women, I² = 42%, moderate quality evidence). This suggests that for a woman

with a 5% risk of OHSS using HCG, the rate would be between nil and 2% with use of a

GnRH agonist. Use of a random-effects model did not substantially affect the results (OR

0.17, 95% CI 0.03 to 0.98; I2 = 42%). (Figure 3)

1.3.2 Donor-recipient cycles: We found evidence of a lower incidence of OHSS in the

GnRH agonist group than in the HCG group (OR 0.05, 95% CI 0.01 to 0.28; three RCTs, 374

women, I² = 0%).

107

Figu

re 2

: For

est p

lot f

or li

ve b

irth

rate

per

wom

an ra

ndom

ised

108

1.4 Incidence of OHSS in autologous cycles: subgroup analysis on luteal support approach: The subgroup analysis based on luteal phase support methods used in the

included studies found no evidence of a difference in OHSS rates between trials that used

luteal phase support with LH activity and trials that used luteal phase support without LH

activity (test for subgroup differences: Chi² = 3.39, df = 1 (P value 0.07), I² = 71%). No

evidence was found of a difference between GnRH agonist and HCG groups among women

who had luteal phase support with LH activity (OR 0.47, 95% CI 0.11 to 2.09; I2 = 25%, five

RCTs), but the OHSS rate was lower in the GnRH agonist group among women who had

luteal phase support without LH activity (OR 0.04, 95% CI 0.01 to 0.34; I2 = 0%).

Secondary outcomes1.5 Ongoing pregnancy rate per woman randomised1.5.1 Fresh autologous cycles: GnRH agonist trigger was associated with a lower ongoing

pregnancy rate when compared with HCG (OR 0.70, 95% CI 0.54 to 0.91; 11 RCTs, 1198

women, I² = 54%, moderate-quality evidence).

1.5.2 Donor-recipient cycles: We observed no evidence of differences between groups in

ongoing pregnancy rate (OR 0.88, 95% CI 0.58 to 1.32; three RCTs, 374 women, I² = 0%).

1.6 Ongoing pregnancy rate in autologous cycles: subgroup analysis on luteal support approach: The subgroup analysis based on luteal phase support methods used in the

included studies indicated differences in ongoing pregnancy rate between trials that used

luteal phase support with LH activity and those that used luteal phase support without LH

activity (test for subgroup differences: Chi² = 8.1, df = 1 (P value 0.004), I² = 88%). No

evidence was found of differences between groups among women who had luteal phase

support with LH activity (OR 0.89, 95% CI 0.65 to 1.21; I2 = 27%, five RCTs), but the

ongoing pregnancy rate in the HCG group was higher among women who had luteal phase

support without LH activity (OR 0.36, 95% CI 0.21 to 0.62; I2 = 73%, five RCTs, 370 women).

1.7 Clinical pregnancy rate per woman randomised1.7.1 Fresh autologous cycles: We found no evidence of a difference between groups in

clinical pregnancy rate (OR 0.81, 95% CI 0.61 to 1.04; 11 RCTs, 1198 women, I² = 49%).

1.7.2 Donor-recipient cycles: We found no evidence of a difference between groups in

clinical pregnancy rate (OR 0.87, 95% CI 0.57 to 1.33; three RCTs, 372 women, I² = 0%).

1.8 Miscarriage rate per woman randomised1.8.1 Fresh autologous cycles: GnRH agonist trigger was associated with a higher early

miscarriage rate when compared with HCG (OR 1.74, 95% CI 1.10 to 2.75; 11 RCTs, 1198

women, I² = 1%).

109

Figu

re 3

:For

est p

lot f

or O

HSS

inci

denc

e pe

r wom

an ra

ndom

ised

110

1.8.2 Donor-recipient cycle: We found no evidence of differences between groups in

miscarriage rate (OR 1.14, 95% CI 0.56 to 2.32; three RCTs, 372 women, I² = 0%).

1.9 Multiple pregnancy per woman randomised1.9.1 Fresh autologous cycles: We found no evidence of differences between groups in

multiple pregnancy rate (OR 3.00, 95% CI 0.30 to 30.47; two RCTs, 62 women, I² = 0%).

1.9.2 Donor-recipient cycles: We found no evidence of differences between groups in

multiple pregnancy rate (OR 1.73, 95% CI 0.86 to 3.48; three RCTs, 374 women, I² = 0%).

Additional analysesSubgroup and sensitivity analyses10.1 OHSS incidence: effect of riskOHSS in women at low risk of OHSS: No evidence of a difference between GnRh agonist

and HCG was noted in the rate of OHSS among women at low risk of OHSS (OR 0.79, 95%

CI 0.18 to 3.47; six RCTs, 777 women, I2 = 66%). Heterogeneity for this analysis was

substantial, probably as a result of the low event rate, with four of the six RCTs reporting no

events in either arm.

OHSS in women at high risk of OHSS: GnRH agonist was associated with a significantly

lower risk of OHSS when compared with HCG among women at high risk of OHSS (OR 0.06,

95%CI 0.01 to 0.34; three RCTs, 212 women, I2 = 0%).

10.2 Effect of including only moderate or severe OHSS as an outcome

After cases with mild OHSS were excluded, GnRH agonist was associated with lower risk of

moderate or severe OHSS when compared with HCG (OR 0.21, 95% CI 0.07 to 0.66; four

RCTs, 112 women, I2 = 20%). The analysis included only 16 events reported by four RCTs.

A further five RCTs reported no events in either arm. Results were similar among women at

high risk of OHSS: GnRH agonist was associated with significantly lower risk of moderate or

severe OHSS when compared with HCG (OR 0.09, 95%CI 0.02 to 0.52; four RCTs, 112

women, I2 = 0%).

10.3 Use of risk ratios rather than odds ratiosUse of risk ratios rather than odds ratios did not materially affect our findings. Findings of

other subgroup and sensitivity analyses are described above, under the section on relevant

comparisons.

Assessment of publication biasA funnel plot was constructed for the outcome of ongoing pregnancy. This plot was not

symmetrical, as a greater number of effect estimates were placed on the left side of the

graph. This could imply publication bias, but in this case it seems more likely that the effect

was due to the fact that the more extreme effect estimates were derived from studies that did

not use luteal support with LH.

111

Discussion

This review update on the benefits and harms of GnRH agonist trigger in subfertile women

treated with GnRH antagonist in IVF/ ICSI treatment cycles found that use of GnRH agonist

trigger compared with HCG triggering was associated with a markedly reduced live birth rate

and an increased early miscarriage rate but was beneficial in preventing OHSS in fresh

autologous cycles among women at high risk of OHSS. No differences between interventions

in OHSS incidence were noted among women at low risk of OHSS. Overall (regardless of

underlying risk) for a woman with a 5% risk of mild, moderate or severe OHSS with use of

HCG, the risk of OHSS with use of a GnRh agonist was between nil and 2%, and for women

with a 5% risk of developing moderate or severe OHSS with use of HCG, the risk with use of

a GnRH antagonist was between nil and 3%. In donor-recipient cycles, use of GnRH agonist

instead of HCG also resulted in a lower incidence of OHSS. No evidence was found of a

difference in live birth or ongoing pregnancy rate, although the results were consistent with

those for fresh autologous cycles.

GRADE assessment found that evidence for most review outcomes was of moderate quality.

Exceptions included ongoing pregnancy and multiple pregnancy, which were rated as having

low-quality evidence. Reasons for downgrading evidence quality included poor reporting of

study methods, premature study termination, failure to blind outcome assessment and

statistical heterogeneity. For some outcomes, confidence intervals were wide as the result of

low event rates. The authors of four studies stated that the studies were commercially

funded. The authors of most studies failed to disclose their funding source.

Strengths of this review include comprehensive systematic searching for eligible studies,

rigid inclusion criteria for RCTs and data extraction and analysis by two independent review

authors. Furthermore, the possibility of publication bias was minimised by inclusion of both

published and unpublished studies (such as abstracts from meetings). However, as with any

review, we cannot guarantee that we found all eligible studies.

Our results are in agreement with those of a previous review (Griesinger 2006). However,

that review included only three small randomised controlled studies (Fauser 2002; Humaidan

2005; Kolibianakis 2005) involving 275 randomised women. How can poor reproductive

outcomes following oocyte triggering with GnRH agonist be explained? In previous studies,

oocyte maturity, fertilisation rate and embryo development were comparable between GnRH

agonist and HCG-induced final oocyte maturation. This was found both in fresh autologous

cycles (Griesinger 2006) and in donor cycles (Bodri 2009; Erb 2009). Furthermore, frozen-

thawed cycles with embryos obtained after oocyte triggering with GnRH agonist resulted in

high pregnancy rates (Griesinger 2007a; Griesinger 2007b). Hence, oocyte triggering with

GnRH agonist appears to have no major impact on oocyte and embryo quality. It seems

more likely that GnRH agonist induces a luteal phase defect. This luteal phase defect may

112

result from the short half-life of the induced LH surge, leading to premature luteolysis of

corpus luteum and significantly lower steroidal and non-steroidal hormones, thus affecting

endometrial receptivity (Lanzone 1994; Peñarrubia 1998; Nevo 2003; Emperaire 2004;

Humaidan 2005).

Consequently, further studies have been conducted to evaluate different modified luteal

phase strategies with LH activity supplementation in terms of administration of small dosages

of HCG around the time of oocyte maturation trigger (Humaidan 2010;Humaidan 2013) or

with repeated administration of recLH (Papanikolaou 2010), or without LH supplementation

but with the help of progesterone and oestradiol administration (Engmann 2008).Our

subgroup analysis shows that, although modified luteal phase support with LH was

associated with pregnancy rates almost comparable with those of HCG, the difference in

OHSS risk was no longer present. Apparently, available regimens could not compensate for

the induced luteal phase defect in GnRH agonist triggered cycles.

Our meta-analysis of fresh autologous cycles and donor-recipient cycles found that use of a

GnRH agonist trigger is associated with a significantly reduced incidence of OHSS when

compared with HCG, as none of the women in the pooled studies developed any form of

OHSS when in the GnRH agonist group. The shorter half-life of the endogenous LH surge

and subsequent pituitary suppression and withdrawal of LH support for the corpora luteum

may lead to early luteolysis (Kol 2004; Kol 2008).Moreover, significantly lower luteal levels of

inhibins and steroid hormones suggest that the corpora luteum may secrete lower levels of

other non-steroidal substances, and the vasoactive properties of vascular endothelial growth

factor (VEGF) may be involved in OHSS. This may explain the mechanism of OHSS

prevention with the use of GnRH agonists (Nevo 2003; Cerrillo 2011).

We conclude that the evidence suggests that GnRH agonist as a final oocyte maturation

trigger in fresh autologous cycles is associated with a lower live birth rate, a lower ongoing

pregnancy rate (pregnancy beyond 12 weeks) and a higher rate of early miscarriage (less

than 12 weeks). GnRH agonist as an oocyte maturation trigger could be useful for women

who choose to avoid fresh transfers (for whatever reason), women who donate oocytes to

recipients or women who wish to freeze their eggs for later use in the context of fertility

preservation.

113

References

Included studies

• Acevedo B, Jose Gomez-Palomares L, Ricciarelli E, Hernández ER. Triggering ovulation with gonadotropin releasing hormone agonists does not compromise embryo implantation rates. Fertility and Sterility 2006; 86(6):1682–7.

• Babayof R, Margalioth J E, Huleihel M, Amash A, Zylber-Haran E, Gal M, et al.Serum inhibin A, VEGF and TNFa levels after triggering oocyte maturation with GnRH agonist compared with HCG in women with polycystic ovaries undergoing IVF treatment: a prospective randomized trial. Human Reproduction 2006; 21(5):1260-5.

• Beckers NG, Macklon NS, Eijkemans MJ, Ludwig M,Felberbaum RE, Diedrich K, et al. Non supplemented luteal phase characteristics after the administration of recombinant human chorionic gonadotropin, recombinant luteinizing hormone, or gonadotropin-releasing hormone (GnRH) agonist to induce final oocyte maturation in in vitro fertilization patients after ovarian stimulation with recombinant follicle-stimulating hormone and GnRH antagonist cotreatment. The Journal of Clinical Endocrinology and Metabolism 2003; 88(9):4186-92. [DOI: 10.1210/jc.2002-021953]

• Engmann L, DiLuigi A, Schmidt D, Nulsen J, Maier D,Benadiva C. The use of gonadotropin-releasing hormone (GnRH) agonist to induce oocyte maturation after cotreatment with GnRH antagonist in high-risk patients undergoing in vitro fertilization prevents the risk of ovarian hyperstimulation syndrome: a prospective randomized controlled study. Fertility and Sterility 2008;89(1):84–91.[DOI: :10.1016/j.fertnstert.2007.02.002]

• Fauser BC, De Jong D, Olivennes F, Warmsby H, Tay CJ,Itskovitz-Eldor J, Van Hooren HG. Endocrine profiles after triggering of final oocyte maturation with GnRH agonist after cotreatment with the GnRH antagonist ganirelix during ovarian hyperstimulation for in vitro fertilization. The Journal of Clinical Endocrinology and Metabolism 2002; 87(2):709–15.

• Galindo A, Bodri D, Guillén JJ, Colodrón M, Vernaeve V, Coll O. Triggering with HCG or GnRH agonist in GnRH antagonist treated oocyte donation cycles: a randomised clinical trial. Gynecology Endocrinolology 2009; 25(1):60–6.

• Humaidan P, Bredkjær HE, Bungum L, Bungum M,Grøndahl ML,Westergaard L, Andersen CY. GnRH agonist (buserelin) or hCG for ovulation induction in GnRH antagonist IVF/ICSI cycles: a prospective randomized study. Human Reproduction 2005; 20(5):1213-20. [DOI:10.1093/humrep/deh765].

114

• Humaidan P, Bungum M, Andersen CY. Rescue of corpusluteum function with periovulatory HCG supplementationin IVF/ICSI GnRH antagonist cycles in which ovulation was triggered with a GnRH agonist: a pilot study. Reproductive BioMedicine Online 2006; 13(2):173–8.

• Humaidan P, Bredkjær HE, Westergaard L, Andersen CY.1500 IU hCG secures a normal clinical pregnancy outcome in IVF/ICSI GnRH antagonist cycles in which ovulation was triggered with a GnRH agonist. Fertility and Sterility 2010; 93(3):847–54. [DOI: 10.1016/j.fertnstert.2008.12.042]

• Humaidan P, Polyzos NP, Alsbjerg B, Erb K, Mikkelsen AL, Elbaek HO, et al. GnRHa trigger and individualized luteal phase hCG support according to ovarian response to stimulation: two prospective randomized controlled multicentre studies in IVF patients. Human Reproduction 2013; 28(9):2511–21.

• Kolibianakis EM, Schultze-Mosgau A, Schroer A, VanSteirteghem A, Devroey P, Diedrich K, et al. A lower ongoing pregnancy rate can be expected when GnRH agonist is used for triggering final oocyte maturation instead of HCG in patientsundergoing IVF with GnRH antagonists. Human Reproduction 2005; 20(10):2887-92. [DOI: 10.1093/humrep/dei150; : PUBMED].

• MeloM, Busso CE, Bellver J, Alama P, Garrido N, MeseguerM, et al. GnRH agonist versus recombinant HCG in an oocyte donation programme: a randomized, prospective, controlled, assessor-blind study. Reproductive Biomedicine Online 2009;19(4):486–92.

• Ossina E, Yavorovskaya K, Kuzmichev L, Kornilov N,Belikov V, Belikova O, et al. Triggering of final oocyte maturation in GnRH antagonist IVFprotocols : triptorelin0.1 mg versus hCG. A randomized multi centre trial. Abstracts of the 20th Annual Meeting of the ESHRE, Berlin, Germany, 27-30 June 2004; 19(1):i99–i102.

• Papanikolaou EG, Verpoest W, Fatemi H, TarlatzisB, Devroey P, Tournaye H. A novel method of luteal supplementation with recombinant luteinizing hormone when agonadotropin-releasing hormone agonist is used instead of human chorionic gonadotropin for ovulation triggering: a randomized prospective proof of concept study. Fertility and Sterility 2011; 95(3):1174–7.

• Peña V, Chinea E, Sanabria V, Hernandez J, Palumbo A. Triggering final oocyte maturation with a GnRH agonist in egg donors does not reduce implantation and pregnancy rates and eliminates the risk of OHSS. Abstracts of the 23rd Annual Meeting of the ESHRE, Lyon, France, 1-4 July 2007; 22(1):i123.

115

• Pirard C, Donnez J, Loumaye E. GnRH agonist as luteal phase support in assisted reproduction technique cycles: results of a pilot study. Human Reproduction 2006;21(7):1894–900. [DOI: 10.1093/humrep/del072]

• Segal S, Casper RF. Gonadotropin-releasing hormone agonist versus human chorionic gonadotropin for triggering follicular maturation in in vitro fertilization. Fertility and Sterility 1992; Vol. 57, issue 6:1254–8.

Excluded studies• Andersen CY, Humaidan P, Ejdrup HP, Bungum L, Grøndah ML, Westergaard LG.

Hormonal characteristics of follicular fluid from women receiving either GnRH agonist or hCG for ovulation induction. Human Reproduction 2006; 21(8):2126–30.

• Murray AM, Soto-Albors C. Use of combined oral and vaginal estradiol and IM and vaginal progesterone in luteal phase of antagonist cycles triggered with GnRH agonist results in good clinical pregnancy rates. Fertility and Sterility 2011; 45:S25.

• Awwad JT, Hannoun AB, Khalil A, Younes ZM, Ghazeeri GS. Induction of final follicle maturation with a gonadotropin-releasing hormone agonist in women at risk of ovarian hyperstimulation syndrome undergoing gonadotropin stimulation and intrauterine insemination: proof-of-concept study. Clinical and Experimental Obstetrics and Gynecology 2012; 39(4):436-9.

• Bankowski B, Bracero N, King J, Garcia J, Wallach E, Vlahos N. Triggering ovulation with leuprolide acetate is associated with lower pregnancy rates. Abstracts of the 20th Annual Meeting of the ESHRE, Berlin, Germany, 27–30 2004; 19 Suppl 1:i103.

• Beckers NG, Macklon NS, Eijkemans MJ, Ludwig M, Felberbaum R, Bustion S, et al. Comparison of the non supplemented luteal phase characteristics after recombinant luteinizing hormone (r) HCG, rLH or GnRH agonist for oocyte maturation in IVF. In: Abstracts of the 18th annual meeting of the ESHRE. Vol. 17. 2002:55.

• Bennett RA, Vidali A, Walker J, Navot D. Triggering ovulation with GnRH agonist to avoid ovarian hyperstimulation, frequently results in profound corpus luteum insufficiency. Fertility and Sterility 1997; 68 Suppl 1:174-5.

• Bodri D, Guillen JJ, Galind A, Mataro D, Pujol A, Coll O. Triggering with human chorionic gonadotropin or a gonadotropin-releasing hormone agonist in gonadotropin-releasing hormone antagonist-treated oocyte donor cycles: findings of a large retrospective cohort study. Fertility and Sterility 2009; 91(2):365-71.

• Bodri D, Guillén JJ, Trullenque M, Schwenn K, Esteve C, Coll O. Early ovarian hyperstimulation syndrome is completely prevented by gonadotropin releasing-hormone agonist triggering in high-risk oocyte donor cycles: a prospective, luteal-phase follow-up study. Fertil Steril. 2010; 93(7):2418-20.

• Bodri D. Low-dose hCG supplementation after GnRH agonist triggering: don't be too quick on the trigger. Hum Reprod 2013; 28(9):2315-7.

116

• Bracero NJ, Jurema MW, Posada MN, Whelan JG, Garcia JE, Vlahos NP. Triggering ovulation with leuprolide acetate (LA) instead of human chorionic gonadotropin (hCG) after the use of ganirelix for in vitro fertilization-embryo transfer (IVF-ET) does not compromise cycle outcome and may prevent ovarian hyperstimulation syndrome. Fertility and Sterility 2001; 76 Suppl 3:93.

• Bukulmez O, Rehman KS, Langley M, Carr BR, Doody KM, Doody KJ. Triggering ovulation by GnRH agonist leuprolide acetate does not adversely affect the number and quality of the oocytes as compared to recombinant hCG in oocyte donation cycles. Abstract of the annual meeting of ASRM 2005; 84 Suppl (1):314-5.

• Carone D, Vizziello GM, Schonauer LM, D’Amato G. Safety and efficacy of GnRH agonist to trigger ovulation in controlled ovarian hyperstimulation for ART with recombinant FSH and GnRH-antagonist in high responders (PCOD) patients. Abstracts of the 8th International Symposium on GnRH-analogues in Cancer and Human Reproduction. Salzburg, Austria 2005; A24.

• Castillo JC, Dolz M, Evangelio B, Abad de Velasco L, Bonilla-Musoles F. Efficacy and security of luteal phase support with low doses of HCG in OHSS high risk patients triggered with GnRH agonists. Abstracts of the 23rd Annual Meeting of the ESHRE, Lyon, France, 1–4 July 2007; 22(1): i 81.

• Cerrillo M, Pacheco A, Rodríguez S, Mayoral M, Ruiz M, García Velasco JA. Differential regulation of VEGF, cadherin, and angiopoietin 2 by trigger oocyte maturation with GnRHa vs. hCG in donors: try to explain the lower OHSS incidence. Abstracts of the 25th annual meeting of the ESHRE, Amsterdam, June 28-1 July, 2009; 24(1):i60.

• Check J, Nazari A, Barnea E, Weiss W, Vetter B. The efficacy of short-term gonadotrophin-releasing hormone agonists versus human chorionic gonadotrophin to enable oocyte release in gonadotrophin stimulated cycles. Human Reproduction 1993; 8:568-71.

• Chen SL, Dong H, Xing FQ. Clinical study of buserelin, instead of hCG, used for triggering follicular maturation in infertile patients with PCOS. Fertility and Sterility 1998; 70(3):S396.

• Chen SL, Ye DS, Chen X, Yang XH, Zheng HY, Tang Y, et al. Circulating luteinizing hormone level after triggering oocyte maturation with GnRH agonist may predict oocyte yield in flexible GnRH antagonist protocol. Human Reproduction 2012;27(5):1351-6.

• Cunha Filho J, Gratao A, Souza C, Freitas F, Vettori D, Passos E. Prospective randomized clinical trial to evaluate embryo quality (score) after GnRH agonist or HCG administration to induce oocyte maturation. Human Reproduction 2002;17(1):150, Abstract no: P-440.

• Daneshmand ST, Shapiro BS, Garner FC, Aguirre M, Ross R. Cumulative pregnancy rates when using GnRH agonists instead of HCG for final oocyte maturation. Abstract of the annual meeting of ASRM 2006; 86 Suppl (2):184-5.

117

• De Jong D, Van Hooren EG, Macklon NS, Mannaerts BM, Fauser B. Pregnancy and birth after GnRH agonist treatment for induction of final oocyte maturation in a woman undergoing ovarian stimulation for ICSI, using a GnRH antagonist (Orgalutran/Antagon) to prevent a premature LH surge: a case report. Journal of Assisted Reproduction and Genetics 2001;18:30-3

• Diaz I, Guillen A, Pacheco A, Requena A, Simon C, Garcia Velasco J. Final oocyte maturation with GnRH-agonist versus hCG in intrauterine insemination. Abstracts of the 19th annual meeting of the ESHRE. Madrid, Spain, June 29–July 2 2003;18(1):134.

• DiLuigi AJ, Engmann L, Schmidt DW, Maier DB, Nulsen JC, Benadiva CA. Gonadotropin-releasing hormone agonist to induce final oocyte maturation prevents the development of ovarian hyperstimulation syndrome in high-risk patients and leads to improved clinical outcomes compared with coasting. Fertility and Sterility 2010;94(3):1111-4.

• Egbase PE, Grudzinskas JG, Al Sharhan M, Ashkenani L. HCG or GnRH agonist to trigger ovulation in GnRH antagonist-treated intrauterine insemination cycles: a prospective randomized study. Abstracts of the 18th Annual Meeting of the ESHRE, Vienna, Austria 2002 2002; 17(1):2.

• Eldar-Geva T, Zylber-Haran E, Babayof R, Halevy-Shalem T, Ben-Chetrit A, Tsafrir A, et al. Similar outcome for cryopreserved embryo transfer following GnRH antagonist/GnRH agonist, GnRH -antagonist/HCG or long protocol ovarian stimulation. Reproductive BioMedicine Online 2007; 14(2):148-54.

• Emperaire JC, Ruffie A, Audebert AJ. [Ovulation induction by endogenous LH released by the administration of an LHRH agonist after follicular stimulation for in vitro fertilization]. Journal de Gynecologie, Obstetrique et Biologie de la Reproduction 1992;21:489-94.

• Engmann LA, Diluigi D, Schmidt J, Nulsen D, Maier C, Benadiva. Prevention of ovarian hyperstimulation syndrome (OHSS) with the use of gonadotropin releasing hormone (GnRH) agonist to trigger final oocyte maturation after cotreatment with GnRH antagonist in patients with polycystic ovarian syndrome (PCOS) or previous high response undergoing IVF treatment. A prospective randomized clinical trial. Abstract of the annual meeting of ASRM 2005; 84 Suppl (1):96.

• Engmann L, Siano L, Weitzman V, Nulsen J, Maier D, Benadiva C. Induction of oocyte maturation with GnRH agonists in high-risk patients undergoing IVF treatment does not adversely affect implantation rate. Fertility and Sterility 2006; 86(1):797-8.

• Engmann L, Siano L, Schmidt D, Nulsen J, Maier D, Benadiva C. GnRH agonist to induce oocyte maturation during IVF in patients at high risk of OHSS. Reproductive BioMedicine Online 2006; 13(5):639-44.

• Engmann L, Romak J, Nulsen J, Benadiva C, Peluso C. In vitro viability and secretory capacity of human luteinized granulosa cells after gonadotropin-releasing hormone agonist trigger of oocyte maturation. Fertility and Sterility 2011; 96(1):198-202.

118

• Engmann L, Benadiva C. Agonist trigger: what is the best approach? Agonist trigger with aggressive luteal support. Fertility and Sterility 2012; 97(3):531-3.

• Erb TM, Vitek W, Wakim AN. Gonadotropin-releasing hormone agonist or human chorionic gonadotropin for final oocyte maturation in an oocyte donor program. Fertility and Sterility 2010; 93(2):374-8.

• Fatemi HM, Polyzos NP, van Vaerenbergh I, Bourgain C, Blockeel C, Alsbjerg B, et al. Early luteal phase endocrine profile is affected by the mode of triggering final oocyte maturation and the luteal phase support used in recombinant follicle-stimulating hormone-gonadotropin-releasing hormone antagonist in vitro fertilization cycles. Fertility and Sterility 2013; 100(3):742-7.

• Galera F, Rayward J, Verdu V, Villafanez V, Manzanares MA, Garijo E. GnRH agonist triggered LH surge: P4, E2 levels. IVF outcome. Abstracts of the 21st Annual meeting of the ESHRE , Copenhagen, Denmark, 19-22, 2005;20(1):i 109.

• Garcia-Velasco JA, Motta L, López A, Mayoral M, Cerrillo M, Pacheco A. Low-dose human chorionic gonadotropin versus estradiol/progesterone luteal phase support in gonadotropin-releasing hormone agonist-triggered assisted reproductive technique cycles: understanding a new approach. Fertility and Sterility 2010; 94(7):2820-3.

• Garcia-Velasco JA. Agonist trigger: what is the best approach? Agonist trigger with vitrification of oocytes or embryos. Fertility and Sterility 2012; 97(3):527-8.

• Goto T, Oka C, Tatsuhiro T, Mukaida T, Takahashi K. Single dose nasal spray of gonadotropin releasing hormone (GnRH) agonist effectively matures oocytes for in vitro fertilization in an ovarian stimulation protocol using clomiphene citrate, gonadotropin, and GnRH antagonist. Abstracts of the Annual Meeting of the ASRM 2003; 80 Suppl (3):6.

• Griesinger G, Schultze-Mosgau A, Schroer A, Van Steirteghem A, Devroey P, Diedrich K, et al. GnRH-agonist instead of hCG for final oocyte maturation in GnRH-antagonist cycles. 21st Annual Meeting of the European Society of Human Reproduction and Embryology, Copenhagen, Denmark, 19-22 June 2005 2005;i91.

• Griesinger G, Kolibianakis EM, Papanikolaou EG, Diedrich K, Van Steirteghem A, Devroey PC. Triggering of final oocyte maturation with gonadotropin-releasing hormone agonist or human chorionic gonadotropin. Live birth after frozen-thawed embryo replacement cycles. Fertility and Sterility 2007; 88(3):616-21.

• Griesinger G, Von Otte S, Schroer A, Ludwig AK, Diedrich K, Al-Hasani S, et al. Elective cryopreservation of all pro nuclear oocytes after GnRH agonist triggering of final oocyte maturation in patients at risk of developing OHSS: a prospective, observational proof-of-concept study. Human Reproduction 2007;22(5):1348–52

• Griesinger G, Berndt H, Schultz L, Depenbusch M, Schultze-Mosgau A. Cumulative live birth rates after GnRH-agonist triggering of final oocyte maturation in patients at risk of OHSS: a prospective, clinical cohort study. European Journal of Obstetric and Gynecologic Reproduction Biology 2010; 149(2):190-4.

119

• Griesinger G1, Schultz L, Bauer T, Broessner A, Frambach T, Kissler S. Ovarian hyperstimulation syndrome prevention by gonadotropin-releasing hormone agonist triggering of final oocyte maturation in a gonadotropin-releasing hormone antagonist protocol in combination with a "freeze-all" strategy: a prospective multicentric study. Fertility and Sterility 2011; 95(6):2029-33.

• Griffin D, Benadiva C, Kummer N, Budinetz T, Nulsen J, Engmann L. Dual trigger of oocyte maturation with gonadotropin-releasing hormone agonist and low-dose human chorionic gonadotropin to optimize live birth rates in high responders. Fertility and Sterility 2012; 97(6):1316-20.

• Herrero L, Pareja S, Losada C, et al. Avoiding the use of human chorionic gonadotropin combined with oocyte vitrification and GnRH agonist triggering versus coasting: a new strategy to avoid ovarian hyperstimulation syndrome. Fertility andSterility 2010; 95(3):1137-40.

• Humaidan P, Westergaard LG, Mikkelsen AL, Fukuda M, Yding Andersen C. Levels of the epidermal growth factor-like peptide amphiregulin in follicular fluid reflect the mode of triggering ovulation: a comparison between gonadotrophin-releasing hormone agonist and urinary human chorionic gonadotrophin. Fertility and Sterility 2011;95(6):2034-8

• Humaidan P, Van Vaerenbergh I, Bourgain C, Alsbjerg B, Blockeel C, Schuit F, et al. Endometrial gene expression in the early luteal phase is impacted by mode of triggering final oocyte maturation in recFSH stimulated and GnRH antagonist co-treated IVF cycles. Human Reproduction 2012; 27(11):3259-72.

• Imbar T, Kol S, Lossos F, Bdolah Y, Hurwitz A, Haimov-Kochman R. Reproductive outcome of fresh or frozen-thawed embryo transfer is similar in high-risk patients for ovarian hyperstimulation syndrome using GnRH agonist for final oocyte maturation and intensive luteal support. Human Reproduction 2012; 27(3):753-9.

• Itskovitz-Eldor J, Kol S, Mannaerts B. Use of a single bolus of GnRH agonist triptorelin to trigger ovulation after GnRH antagonist ganirelix treatment in women undergoing ovarian stimulation for assisted reproduction, with special reference to the prevention of ovarian hyperstimulation syndrome: preliminary report. Human Reproduction 2000; 15(9):1965-8.

• Johnston-MacAnanny EB, DiLuigi AJ, Benadiva CA, Maier DB, Nulsen JC, Engmann LL. Choice of medication for oocyte maturation for in vitro fertilization (IVF) gonadotropin releasing hormone (GnRH) antagonist cycles; Human chorionic gonadotropin (HCG) vs. leuprolide acetate (LA). Abstract of the annual meeting of ASRM 2007; 88 Suppl (1):142.

• Joo JK, Choi JR, Son JB, Ko GR, Lee KS. Preliminary clinical outcome of novel strategy for the maximization of cumulative pregnancy rates per retrieval in normal responders. Clinical and Experimental Reproductive Medicine 2012; 39(1):33-9.

120

• Kaur H, Krishna D, Shetty N, Krishnan S, Srinivas MS, Rao KA. Effect of pre-ovulatory single dose GnRH agonist therapy on IVF outcome in GnRH antagonist; a prospective study. Journal of Reproduction and Infertility 2012; 13(4):225-31.

• Kol S, Homburg R, Alsbjerg B, Humaidan P. The gonadotropin-releasing hormone antagonist protocol—the protocol of choice for the polycystic ovary syndrome patient undergoing controlled ovarian stimulation. Acta Obstetricia et Gynecologica Scandinavica 2012; 91(6):643-7.

• Krause BT, Ohlinger O. Safety and efficacy of low dose hCG for luteal support after triggering ovulation with a GnRH agonist in cases of polyfollicular development. European Journal of Obstetrics, Gynecology, and Reproductive Biology 2006;126:87–92.

• Kummer NE, Feinn RS, Griffin DW, Nulsen JC, Benadiva CA, Engmann LL. Predicting successful induction of oocyte maturation after gonadotropin-releasing hormone agonist (GnRHa) trigger. Human Reproduction 2013; 28(1):152-9.

• LaMonica R, Siano LJ, Nulsen JC, Maier DB, Benadiva CA, Engmann LL. Elective cryopreservation of all embryos after GnRH agonist trigger is not justified because of the comparable success rates between fresh and cryo-thawed embryo transfers. Abstracts of the annual meeting of ASRM 2007; 88 Suppl (1):135.

• Lanzone A, Fulghesu AM, Villa P, Guida C, Guido M, Nicoletti MC, et al. Gonadotropin-releasing hormone agonist versus human chorionic gonadotropin as a trigger of ovulation in polycystic ovarian disease gonadotropin hyperstimulated cycles. Fertility and Sterility 1994; 62(1):35-41.

• Lanzone A, Fulghesu AM, Villa P, Guida C, Guido M, Nicoletti MC, et al. Gonadotropin-releasing hormone agonist versus human chorionic gonadotropin as a trigger of ovulation in polycystic ovarian disease gonadotropin hyperstimulated cycles [erratum appears in Fertil Steril 1995 Mar 63(3):684-5]. Fertility and Sterility 1994;62(1):35-41.

• Lewit N, Kol S, Manor D, Itskovitz-Eldor J. Comparison of gonadotrophin-releasing hormone analogues and human chorionic gonadotrophin for the induction of ovulation and prevention of ovarian hyperstimulation syndrome. Human Reproduction 1996;11(7):1399-402.

• Lin YH, Huang MZ, Hwang JL, Chen HJ, Hsieh BC, Huang LW, et al. Combination of cabergoline and embryo cryopreservation after GnRH agonist triggering prevents OHSS in patients with extremely high estradiol levels—a retrospective study. Journal of Assisted Reproduction and Genetics 2013; 30(6):753-9.

• Lin MH, Shao-Ying Wu F, Kuo-Kuang lee R, Li SH, Lin SY, Hwu YM. Dual trigger with combination of gonadotropin-releasing hormone agonist and human chorionic gonadotropin significantly improves the live-birth rate for normal responders in GnRH-antagonist cycles. Fertilty and Sterility 2013; 100(5):1296-302.

121

• Iliodromiti S, Blockeel C, Tremellen KP, Fleming R, Tournaye H, Humaidan P, et al. Consistent high clinical pregnancy rates and low ovarian hyperstimulation syndrome rates in high-risk patients after GnRH agonist triggering and modified luteal support: a retrospective multicentre study. Human Reproduction 2013; 28(9):2529-36.

• Loumaye E, Pirard C, Donnez J. GnRH agonist as a novel luteal support: results of a pilot study. Abstracts of the 20th Annual Meeting of the ESHRE, Berlin, Germany, 27 - 30 June 2004;19(1):i4.

• Loumaye E, Pirard C, Donnez J. Efficacy of GnRH agonist as luteal support: results of a prospective, randomized, comparative study. Abstracts of the 23rd Annual Meeting of the ESHRE, Lyon, France 1-4 July 2007; 22(1):i82.

• Melo M, Busso CE, Bellver J, Alama P, Garrido N, Meseguer M, et al. GnRH agonist versus recombinant HCG in an oocyte donation programme: a randomized, prospective, controlled, assessor-blind study [Melo M, Busso CE, Bellver J, Alama P, Garrido N, Meseguer M, et al. A randomized, prospective, controlled, assessor-blind study, comparing triptorelin vs. rhCG as trigger oocyte maturation in oocyte donors]. 2007 Fertility and Sterility; 88(1):34.

• Meltzer S, Girsh E, Shults A, Katz N, Zohav E, Tur-Kaspa I. Prevention of ovarian hyperstimulation syndrome in high responders undergoing IVF treatment with GnRH antagonist combined with single dose of GnRH agonist, instead of HCG, for the induction of oocyte maturation. Abstracts of the 18th Annual Meeting of the ESHRE 2002; 17 Suppl1:89.

• Nelson SM. Venous thrombosis during assisted reproduction: novel risk reduction strategies. Thrombosis Research 2013; Suppl 1:S1-S3.

• Nevo O, Eldar-Geva T, Kol BS, Itskovitz-Eldor J. Lower levels of inhibin A and pro-Cduring the luteal phase after triggering oocyte maturation with a gonadotropin releasing hormone agonist versus human chorionic gonadotropin. Fertility and Sterility 2003; 79(5):1123-8.

• Olivennes F. Induction of final oocyte maturation by a single dose of GNRH agonist after ganirelix treatment. Gynecological Endocrinology 2001; 15(Suppl 2):7.

• Orvieto R, Zagatsky I, Yullzari-Roll V, La Marca A, Fisch B. Substituting human gonadotropin by gonadotropin-releasing hormone to trigger final follicular maturation, during controlled ovarian hyperstimulation, results in less systemic inflammation. Gynecological Endocrinology 2006; 22(8):437-40.

• Orvieto R, Nahum R, Zohav E, Liberty G, Anteby EY, Meltcer S. GnRH-agonist ovulation trigger in patients undergoing controlled ovarian hyperstimulation for IVF with ultrashort flare GnRH-agonist combined with multidose GnRH-antagonist protocol. Gynecological Endocrinology 2013; 29(1):51-3.

• Parneix I, Emperaire JC, Ruffie A, Parneix P. Triggering of ovulation using different regimens of gonadotropin-releasing hormone agonist or human chorionic gonadotropin. Gynecologie, Obstetrique & Fertilite 2001; 29(2):100-5.

122

• Peñarrubia J, Balasch J, Fábregues F, Creus M, Casamitjana R, Ballescá JL, et al. Human chorionic gonadotrophin luteal support overcomes luteal phase inadequacy after gonadotrophin-releasing hormone agonist-induced ovulations in gonadotrophin-stimulated cycles. Human Reproduction 1998; 13(12):3315-8.

• Ricciarelli E, Acevedo-Martin B, Gomez-Palomares JL, Pareja A, Hernandes ER. Triggering ovulation with GnRH agonists does not compromise embryo implantability. Human Reproduction 2006; 21(Suppl):i35.

• Schachter M, Friedler S, Ron-El R, Zimmerman AL, Strassburger D, Bern O, et al. Can pregnancy rate be improved in gonadotropin -releasing hormone (GnRH) antagonist cycles by administering GnRH agonist before oocyte retrieval? A prospective, randomized study. Fertility and Sterility 2008; 90(4):1087-93.

• Schmidt Sarosi C, Kaplan DR, Sarosi P, Essig MN, Licciardi FL, Keltz M, et al. Ovulation triggering in clomiphene citrate stimulating cycles: human chronic gonadotropin versus a gonadotropin releasing hormone agonist. Journal of Assisted Reproduction & Genetics 1995; 12(3):167-73.

• Schmidt-Sarosi C, Kaplan DR, Sarosi P, Essig MN, Licciardi FL, Keltz M, et al. Ovulation triggering in clomiphene citrate-stimulated cycles: human chorionic gonadotropin versus a gonadotropin releasing hormone agonist. Journal of Assisted Reproduction and Genetics 1995; 12(3):167-74.

• Seyhan A, Ata B, Polat M, Son WY, Yarali H, Dahan MH. Severe early ovarian hyperstimulation syndrome following GnRH agonist trigger with the addition of 1500 IU hCG. Human Reproduction 2013; 28(9):2522-8.

• Shalev E, Geslevich Y, Matilsky M, Ben Ami M. Gonadotrophin-releasing hormone agonist compared with human chorionic gonadotrophin for ovulation induction after clomiphene citrate treatment. Human Reproduction 1995; 10:2541-4.

• Shanis BS, Check JH. Efficacy of gonadotropin-releasing hormone agonists to induce ovulation following low-dose human menopausal gonadotropin stimulation. Recent Progress in Hormone Research 1995; 483-6.

• Shapiro BS, Daneshmand ST, Garner FC, Aguirre M, Ross R. Comparison of human chorionic gonadotropin and gonadotropin-releasing hormone agonist for final oocyte maturation in oocyte donor cycles. Fertility and Sterility 2007; 88(1):237.

• Shapiro BS, Daneshmand ST, Garner FC, Aguirre M, Ross R. Gonadotropin-releasing hormone agonist combined with a reduced dose of human chorionic gonadotropin for final oocyte maturation in fresh autologous cycles of in vitro fertilization. Fertility and Sterility 2008; 90(1):231-3.

• Shapiro BS, Daneshmand ST, Garner FC, et al. Comparison of "triggers" using leuprolide acetate alone or in combination with low-dose human chorionic gonadotropin. Fertility and Sterility 2011; 95(8):2715-7.

123

• Shapiro BS, Daneshmand ST, Restrepo H, Garner FC, Aguirre M, Hudson C. Efficacy of induced luteinizing hormone surge after "trigger" with gonadotropn-releasing hormone agonist. Fertility and Sterility 2011; 95(2):826-8.

• Sismanoglu A1, Tekin HI, Erden HF, Ciray NH, Ulug U, Bahceci M. Ovulation triggering with GnRH agonist vs. hCG in the same egg donor population undergoing donor oocyte cycles with GnRH antagonist: a prospective randomized cross-over trial. Journal of Assisted Reproduction and Genetics 2009; 26(5):251-6.

• Toner JP, Denis AL, Hasty LA, Carpenter S, Bates W. Lupron trigger experience in GnRH antagonist ART cycles. Abstracts of the Annual meeting of the ASRM 2006;86(3):S118-9.

• Westergaard L, Andersen CY, Humaidan P, Bredkjær HE, Bungum L, Bungum M, et al. Significant reduction of clinical pregnancy and implantation rates by use of GnRH agonist (Buserelin) as compared to hCG to induce ovulation in FSH/GnRH antagonist treated IVF/ICSI cycles. Abstracts of the 20th Annual Meeting of the ESHRE, Berlin,Lyon, 27-30 June 2004; 19(1):i3.

• Wilkinson SC, Walker SA, Hayes BA, Donesky BW, Bird JS, Anderson AR. Gonadotropin releasing hormone (GnRH) agonist trigger following antagonist protocols in anonymous oocyte donors minimizes ovarian hyperstimulation syndrome. Abstract of the annual meeting of ASRM 2007; 88(1):S131.

• Yding Andersen C, Westergaard LG, Figenschau Y, Bertheussen K, Forsdahl F. Endocrine composition of follicular fluid comparing human chorionic gonadotrophin to a gonadotrophin-releasing hormone agonist for ovulation induction. Human Reproduction 1993; 8(6):840-3.


• Delvigne A, Rozenberg S. Review of clinical course and treatment of ovarian hyperstimulation syndrome. Human Reproduction Update 2003; 9:77–96.

• Emperaire JC, Parneix I, Ruffie A. Luteal phase defects following agonist-triggered ovulation: a patient-dependent response. Reproductive Biomedicine Online 2004;9:22–7.

• Felberbaum PE, Reissmannb T, Kiipkera W, BaueraO, Al Hasania S, Diedrich C, et al.Preserved pituitary response under ovarian stimulation with HMG and GnRH antagonists (cetrorelix) in women with tubal infertility. European Journal of Obstetrics, Gynecology, and Reproductive Biology 1995; 61:151–5.

• Forman R, Fries N, Tastart J, Belaisch J,Hazout A, FrydmanR. Evidence of an adverse effect of elevated serum estradiol concentrations on embryo implantation. Fertility and Sterility 1998; 49:118–22.

• Golan A, Ron-el R, Herman A, Soffer Y,Weinraub Z, CaspiE. Ovarian hyperstimulation syndrome: an update review. Obstetrical & Gynecological Survey 1989; 44(6):430–40.

124

• Gonen Y, Balakier H, Powell W, Casper RF. Use of GnRH agonist to trigger follicular maturation for in vitrofertilization. The Journal of Clinical Endocrinology andMetabolism 1990; 71:918-23.

• Griesinger G, Diedrich K, Dovroey P, Kolibianakis EM. GnRH agonist for triggering final oocyte maturation in the GnRH antagonist ovarian hyperstimulation protocol: a systematic review and meta-analysis. Human Reproduction Update 2006; 12(2):159–68. [DOI: 10,1093/humrupd/dmi045]

• Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0[updated March 2011]. The Cochrane Collaboration,2011:www.cochrane–handbook.org.

• Humaidan P, Papanikolaou EG, Tarlatzis BC. GnRHa to trigger final oocyte maturation: a time to reconsider. Human Reproduction 2009; 24(10):2389–94.

• Kol S. Luteolysis induced by a gonadotropin-releasing hormone agonists the key to prevention of ovarian hyperstimulation syndrome. Fertility and Sterility 2004; 81(1):1-5.

• Kol S. GnRH agonist for triggering final oocyte maturation in patients at risk of ovarian hyperstimulation syndrome: stilla controversy. Journal of Assisted Reproduction and Genetics2008; 25:63–6. [DOI: 10.1007/s10815-008-9198-1]

• Kol S, Humaidan P. GnRH agonist triggering: recent developments. Reproductive Biomedicine Online 2013; 26(3):226–30.

• Lundh A, Sismondo S, Lexchin J, Busuioc OA, Bero L.Industry sponsorship and research outcome. Cochrane Database Syst Rev 2012;12;12:MR000033:doi:10.1002/14651858.MR000033.pub2. Review.

• Navot D, Bergh PA, Laufer N. Ovarian hyperstimulation syndrome in novel reproductive technologies: prevention and treatment. Fertility and Sterility 1992;58:249–61.

• Olivennes F, Fanchin R, Bouchard P, Taieb J, FrydmanR. Triggering of ovulation by a gonadotropin-releasing hormone (GnRH) agonist in patients pretreated with GnRHantagonist. Fertility and Sterility 1996; 66:151–3.

• Simon C, Cano F, Valbuena D, Remohi J, Pellicer A. Clinical evidence for a detrimental effect on uterine receptivity of high serum estradiol concentrations in high and normal responders. Human Reproduction 1995; 10:2432–7.

• Simon C, Garcia Velasco JJ, Valbuena D, Peinado JA, Moreno C, Rehmohi J, et al. Increasing uterine receptivity by decreasing estradiol levels during the preimplantation period in high responders with the use of a follicle-stimulating hormone step-down regimen. Fertility and Sterility 1998; 70:234–9.

• Tavaniotou A, Albano C, Smitz J, Devroey P. Impact of ovarian stimulation on corpus luteum function and embryonic implantation. Journal of Reproductive Immunology2002; 55:123–30.

125

• Tay CC. Use of gonadotropin-releasing hormone agonist to trigger ovulation. Human Fertility 2002; 5:G35–7.Valbuena 2001

• Valbuena D, Martin J, de Palbo JL, Remohi J, Pellicer A, Simon C. Increasing levels of estradiol are deleterious to embryonic implantation because they directly affect the embryo. Fertility and Sterility 2001; 76:962–8.

References to other published versions of this review• Youssef MA, van der Veen F, Al-Inany HG, Griesinger G, Mochtar MH, van Wely M.

Gonadotropin-releasing hormone agonist versus HCG for oocyte triggering in antagonist assisted reproductive technology cycles. Cochrane Database Syst Rev 2010; 11(CD008046): doi: 10.1002/14651858.CD008046.pub2.

126

Volume expanders for the prevention of ovarian hyperstimulation syndrome.

Youssef MAFM, Mourad S.

Cochrane Database Syst Rev. 2016 Aug 31;(8):CD001302

125

• Youssef MA, van der Veen F, Al-Inany HG, Griesinger G, Mochtar MH, van Wely M. Gonadotropin-releasing hormone agonist versus HCG for oocyte triggering in antagonist assisted reproductive technology cycles. Cochrane Database Syst Rev 2010; 11(CD008046): doi: 10.1002/14651858.CD008046.pub2.

Chapter 6

126

Volume expanders for the prevention of ovarian hyperstimulation syndrome.

Youssef MAFM, Mourad S.

Cochrane Database Syst Rev. 2016 Aug 31;(8):CD001302

127

Abstract

Background: Ovarian hyperstimulation syndrome (OHSS) is a serious and potentially fatal

complication of ovarian stimulation which affects 1% to 14% of all in vitro fertilisation (IVF) or

intracytoplasmic sperm injection (ICSI) cycles. A number of clinical studies with conflicting

results have reported on the use of plasma expanders such as albumin, hydroxyethyl starch

(HES), mannitol, polygeline and dextran as a possible intervention for the prevention of

OHSS. Women with very high estradiol levels, high numbers of follicles or oocytes retrieved,

and women with polycystic ovary syndrome (PCOS), are at particularly high risk of

developing OHSS. Plasma expanders are not commonly used nowadays in ovarian

hyperstimulation. This is mainly because clinical evidence on their effectiveness remains

sparse, because of the low incidence of moderate and severe ovarian hyperstimulation

syndrome (OHSS) and the simultaneous introduction of mild stimulation approaches,

gonadotropin-releasing hormone (GnRH) antagonist protocols and the freeze-all strategy for

the prevention of OHSS.

Objectives: To review the effectiveness and safety of administration of volume expanders

for the prevention of moderate and severe ovarian hyperstimulation syndrome (OHSS) in

high-risk women undergoing IVF or ICSI treatment cycles.

Search methods: We searched databases including the Cochrane Gynaecology and

Fertility Group Specialised Register of controlled trials, the Cochrane Central Register of

Controlled Trials (CENTRAL), MEDLINE, Embase and trial registers to September 2015; no

date restrictions were used as new comparators were included in this search. The references

of relevant publications were also searched. We attempted to contact authors to provide or

clarify data that were unclear from trial or abstract reports.

Selection criteria: We included randomised controlled trials (RCTs) comparing volume

expanders versus placebo or no treatment for the prevention of OHSS in high-risk women

undergoing ovarian hyperstimulation as part of any assisted reproductive technique.

Data collection and analysis: Two review authors independently selected the studies,

assessed risk of bias and extracted relevant data. The primary review outcome was

moderate or severe OHSS. Other outcomes were live birth, pregnancy and adverse events.

We combined data to calculate pooled Peto odds ratios (ORs) and 95% confidence intervals

(CIs) for each intervention. Statistical heterogeneity was assessed using the I(2) statistic. We

assessed the overall quality of the evidence for each comparison, using GRADE methods.

128

Main results: We included nine RCTs (1867 women) comparing human albumin (seven

RCTs) or HES (two RCTs) or mannitol (one RCT) versus placebo or no treatment for

prevention of OHSS. The evidence was very low to moderate quality for all comparisons. The

main limitations were imprecision, poor reporting of study methods, and failure to blind

outcome assessment.There was evidence of a beneficial effect of intravenous albumin on

OHSS, though heterogeneity was substantial (Peto OR 0.67 95% CI 0.47 to 0.95, seven

studies, 1452 high risk women; I² = 69%, very low quality evidence) . This suggests that if the

rate of moderate or severe OHSS with no treatment is 12%, it will be about 9% (6% to12%)

with the use of intravenous albumin. However, there was evidence of a detrimental effect on

pregnancy rates (Peto OR 0.72 95% CI 0.55 to 0.94, I² = 42%, seven studies 1069 high risk

women, moderate quality evidence). This suggests that if the chance of pregnancy is 40%

without treatment, it will be about 32% (27% to 38%) with the use of albumin.There was

evidence of a beneficial effect of HES on OHSS (Peto OR 0.27 95% CI 0.12 to 0.59, I² = 0%,

two studies, 272 women, very low quality evidence). This suggests that if the rate of

moderate or severe OHSS with no treatment is 16%, it will be about 5% (2% to 10%) with the

use of HES. There was no evidence of an effect on pregnancy rates (Peto OR 1.20 95% CI

0.49 to 2.93, one study, 168 women, very low quality evidence).There was evidence of a

beneficial effect of mannitol on OHSS (Peto OR 0.38, 95% CI 0.22 to 0.64, one study, 226

women with PCOS, low quality evidence). This means that if the risk of moderate or severe

OHSS with no treatment is 52%, it will be about 29% (19% to 41%) with mannitol. There was

no evidence of an effect on pregnancy rates (Peto OR 0.85 95% CI 0.47 to 1.55; one study,

226 women, low quality evidence).Live birth rates were not reported in any of the studies.

Adverse events appeared to be uncommon, but were too poorly reported to reach any firm

conclusions.

Authors’ conclusions: Evidence suggests that the plasma expanders assessed in this

review (human albumin, HES and mannitol) reduce rates of moderate and severe OHSS in

women at high risk. Adverse events appear to be uncommon, but were too poorly reported to

reach any firm conclusions, and there were no data on live birth. However, there was

evidence that human albumin reduces pregnancy rates. While there was no evidence that

HES, or mannitol had any influence on pregnancy rates, the evidence of effectiveness was

based on very few trials which need to be confirmed in additional, larger randomised

controlled trials (RCTs) before they should be considered for routine use in clinical practice

129

Background

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic, serious and potentially fatal

complication of ovarian stimulation which affects 1% to 14% of all in vitro fertilisation (IVF) or

intracytoplasmic sperm injection (ICSI) cycles (Garcia-Velasco 2003). OHSS may be

associated with massive ovarian enlargement, extracellular exudate accumulation combined

with profound intravascular volume depletion, ascites, hydrothorax, haemoconcentration,

liver dysfunction and renal failure (Aboulghar 2003; Vloeberghs 2009). It can lead to

cancellation of an IVF cycle and prolonged bed rest or hospitalisation, which may have

significant emotional, social, and economic impacts (Delvigne 2002; Engmann 2008). OHSS

can be classified into an early form that is related to the ovarian response and exogenous

human chorionic gonadotrophin (hCG) administration, and is detected three to nine days

after hCG administration. A late form of OHSS, diagnosed 10 to 17 days later, is due to

endogenous hCG (Mathur 2000) and is categorised as mild, moderate, severe or life-

threatening. The aetiology of OHSS is not completely clear at this moment; however the

syndrome is strongly associated with serum hCG and certain vasoactive substances (Enskog

2001; Rizk 1997).

Many strategies have been tried to prevent OHSS and cycle cancellation such as coasting

(withholding gonadotrophins before the ovulation trigger is given) (D'Angelo 2011),

gonadotropin-releasing hormone (GnRH) agonist as an oocyte trigger in GnRH antagonist

cycles (Kol 2008; Youssef 2014), natural cycle IVF (Edwards 2007), cabergoline (Tang

2012), embryo freezing (D'Angelo 2007), and in vitro oocyte maturation (Loutradis 2006).

Unfortunately, none of the strategies currently employed completely prevent OHSS after

hCG administration (Egbase 2000). Recently the role of vascular endothelial growth factor

(VEGF), as mediator of hCG-dependent ovarian angiogenesis, has emerged (Cerrilo 2009).

VEGF is expressed in human ovaries (Yan 1993) and levels significantly increase after hCG

administration leading to increased vascular permeability (Foong 2006). It has been

proposed that the administration of intravenous fluids such as human albumin, hydroxyethyl

starch (HES), dextran or polygeline might result in a restoration of intravascular volume and

inactivation of the vasoactive intermediates responsible for the pathogenesis of OHSS (Asch

1993; Chen 1997; Isik 1997; Kissler 2001; Shalev 1995).

Albumin has both osmotic and transport functions. It contributes about 75% of the plasma

oncotic pressure and administration of 50 g human albumin solution will draw more than 800

mL of extracellular fluid into the circulation within 15 minutes (McClelland 1990). It has been

suggested that the binding and transport properties of human albumin play a major role in

the prevention of severe OHSS, as albumin may result in binding and inactivation of the

130

vasoactive intermediates responsible for the pathogenesis of OHSS. The osmotic function is

responsible for maintaining the intra-vascular volume in the event of capillary leakage, thus

preventing the sequelae of hypovolaemia, ascites and haemoconcentration (Shalev 1995).

Hydroxyethyl starch (HES) is a plasma expander that has gained recent attention as an

alternative to albumin in reducing the incidence of severe OHSS. Because HES is a non-

biological substance, its use avoids any potential concern about viral transmission that may

be present with albumin (Abramov 2001; Chen 2003a).

Dextran is a complex, branched glucan composed of chains of varying lengths. It is used as

an antithrombotic, to reduce blood viscosity, and as a volume expander in anaemia (Endo

2004).

Polygeline is a type of intravenous colloid with 3.5% urea-linked gelatin used to treat OHSS

(Gamzu 2002). It is used in the prevention or treatment of shock associated with reduction in

effective circulating blood volume due to haemorrhage, loss of plasma or loss of water and

electrolytes from persistent vomiting and diarrhoea.

Mannitol is a naturally occurring sugar alcohol used for its osmotic diuretic purposes; it is

used as plasma expander for the protection of renal failure and in cases of intracerebral

oedema (Shawkat 2012).

OHSS is one of the most common adverse effects of assisted reproductive technology-

controlled ovarian hyperstimulation (ART-COH) cycles. OHSS can result in hospital

admission and in some cases in critical illness. Therefore the aim of this review is to evaluate

the evidence from randomised controlled trials (RCTs) to determine whether volume

expanders can reduce the incidence of moderate and severe OHSS in high-risk women

undergoing IVF/ICSI treatment This review provides a new evidence base for physicians and

stakeholders considering the use of plasma expanders in women at high risk of developing

OHSS who are undergoing IVF/ICSI treatment. This is an update of a Cochrane review first

published in 1999, and previously updated in 2002 and 2011.

Objectives: To investigate the effectiveness and safety of administration of volume

expanders in the prevention of moderate and severe ovarian hyperstimulation syndrome

(OHSS) in high-risk women undergoing in vitro fertilisation (IVF) or intracytoplasmic sperm

injection (ICSI) treatment cycles.

131

Methods

Criteria for considering studies for this review

Types of studies; we included Published and unpublished randomised controlled trials

(RCTs). We excluded non-randomised and quasi-randomised studies (e.g. studies with

evidence of inadequate sequence generation such as alternate days, patient numbers) as

they are associated with a high risk of bias. Cross-over studies were also excluded, as the

design is not valid in this context.

Types of participants: Women of reproductive age who were having controlled ovarian

hyperstimulation as part of any assisted reproductive technique and were considered to be at

high risk of severe OHSS (as determined by either a diagnosis of PCOS (criterion new to the

2015 update), a specific threshold serum estradiol level, a threshold number of follicles on day of HCG administration or threshold number of retrieved oocytes (as defined in individual

studies).

Types of interventions

All kinds of volume expanders used in the prevention of OHSS.

For example:

• Intra-venous albumin versus placebo or no treatment

• Hydroxyethyl starch versus placebo or no treatment

• Mannitol versus placebo or no treatment

• Haemaccel versus placebo or no treatment

• Dextran versus placebo or no treatment

Types of outcome measures

Primary outcomes

1. Moderate and severe OHSS (as determined by established clinical criteria like

(Humaidan 2010, Rizk 1999, Navot 1992, Orvieto and Ben-Rafael 1998, Golan 1989,

Schenker 1978, WHO 1973 ). The 2015 update included for the first time additional

analyses for 'moderate OHSS' on top of the original outcome measure of 'severe

OHSS' from the primary study protocol.

132

Secondary outcomes

2. live birth rate per woman randomised

3. Pregnancy rate per woman randomised (as confirmed by β-HCG or pregnancy test or

ultrasonic visualisation of fetal heart beat at a certain gestational age (as defined in

the separate studies)

4. Adverse effects of treatment (e.g. allergic reaction)

Search methods for identification of studies; We searched for published and unpublished

RCTs of diverse intravenous fluids versus placebo or no treatment using a systematic search

strategy, without date or language restriction and in consultation with the Cochrane

Gynaecology and Fertility (formerly Menstrual Disorders and Subfertility Group (MDSG))

Information Specialist.

Electronic searches: The following electronic databases, trial registers and web sites were

searched to September 2015:

• Ovid Cochrane Central Register of Controlled Trials (CENTRAL)

• Ovid MEDLINE

• Ovid EMBASE: EMBASE

• Ovid PsycINFO

• MEDLINE and EMBASE search strategies use different filters for identifying

randomised trials. The MEDLINE search was combined with the Cochrane highly

sensitive search strategy for identifying randomised trials which appears in the

Cochrane Handbook of Systematic Reviews of Interventions.

• The EMBASE and CINAHL searches were combined with trial filters developed by the

Scottish Intercollegiate Guidelines Network (SIGN)

(www.sign.ac.uk/mehodology/filters.html#random)

• Trial registers for ongoing and registered trials including www.controlled-trials.com/,

https://clinicaltrials.gov and www.who.int/trialsearch/Default.aspx

• The Web of Knowledge (for conference abstracts, and to check citations of included

studies)

Searching other resources; we had searched the reference lists of all primary studies and

review articles retrieved by the search, and checked the citation lists of relevant publications.

We contacted known experts in the field and personal contacts regarding any unpublished

materials. Data collection and analysis: Selection of studies: Two review authors (MY, HG or

SM) independently reviewed the titles and abstracts of studies using the a priori criteria for

133

inclusion. The full-text manuscripts of studies were obtained for the short-listed papers that

were considered potentially eligible for inclusion. We sought further information from the

authors of study reports that did not contain sufficient information to make a decision about

eligibility. Two review authors (MY, HG or SM) independently critically appraised these

studies and any disagreements were resolved by referral to a third review author (MA or JH).

The studies that were determined to be suitable for inclusion were assessed for risk of bias

and data were extracted by two review authors (MY, HG or SM). Subsequently, a detailed

'Characteristics of excluded studies' table was constructed for those studies that did not

satisfy the inclusion criteria. A similar 'Characteristics of included studies' table was

constructed for those studies considered suitable for inclusion.

The 2016 selection process was documented with a study flow diagram (Figure 1).

Data extraction and management: A standardised data extraction form was developed and

piloted for consistency and completeness. Two review authors (MY, HG or SM)

independently performed data extraction. The two sets of extracted data were compared and

discrepancies were resolved by discussion. Where studies had multiple publications, the

review authors collated multiple reports so that each study rather than each report was the

unit of interest in the review; overlapping data were thus identified and duplicates were

excluded. We requested extra information about the methodological quality of some studies

(Bellver 2003; Gokmen 2005; Isik 1996; Isikoglu 2007; Saremi 2003; Shalev 1995; Shoham

1994), however the only response we received was from the authors of Isikoglu 2007 and

Saremi 2003.

Assessment of risk of bias in included studies: Two review authors independently

evaluated the included studies for risk of bias using the Cochrane 'Risk of bias' assessment

tool (Higgins 2011) to assess: selection (random sequence generation and allocation

concealment); performance (blinding of participants and personnel); detection (blinding of

outcome assessors); attrition (incomplete outcome data); reporting (selective reporting); and

other bias. Disagreements were resolved by discussion.

Measures of treatment effect: All data were dichotomous. The numbers of events in the

control and intervention groups of each study were used to calculate Peto odds ratios (ORs)

for each comparison, with 95% confidence intervals (CIs). The choice for a random-effects

model is based on the assumption that events are rare and studies are not all estimating the

same intervention effect, but effects that follow a distribution across studies (Cochrane

Handbook of Systematic Reviews of Interventions section 9.5.4; Higgins 2011).

134

Unit of analysis issues: The primary analysis was per woman randomised. Only one cycle

per woman could be included.

Dealing with missing data: The data were analysed on an intention-to-treat basis as far as

possible and attempts were made to obtain missing data from the original trials. Where these

were unobtainable, only the available data were analysed.

Assessment of heterogeneity: We considered whether the clinical and methodological


clinically meaningful summary. We assessed statistical heterogeneity by visual inspection of

the forest plots, and used the I2 statistic (Higgins 2011) to quantify any apparent

inconsistency, interpreted in the broad terms:

-0 % to 40% might not be important

-30 % to 60% represented moderate heterogeneity

-50 % to 90% represented substantial heterogeneity

- 75 % to 100% represented considerable heterogeneity.


publication bias and other reporting biases, the review authors aimed to minimise their

potential impact by ensuring a comprehensive search for eligible studies and by being alert

for duplication of data. Had there been 10 or more studies in an analysis, we planned to use

a funnel plot to explore the possibility of small-study effects (a tendency for estimates of the

intervention effect to be more beneficial in smaller studies)

Data synthesis: If the studies were sufficiently similar, data from primary studies were

combined using a fixed-effect model to compare IV intervention fluids versus no treatment or

placebo. Analyses were stratified by the type of intervention. We did not pool the stratified

data.

Subgroup analysis and investigation of heterogeneity: Had we detected substantial

heterogeneity, we planned to explore possible explanations in sensitivity analyses and to

take any statistical heterogeneity into account when interpreting the results.

Sensitivity analysis: Sensitivity analyses were conducted for the primary outcomes to

determine whether the conclusions were robust to arbitrary decisions made regarding

eligibility and in the analysis. These analyses included consideration of whether conclusions

would have differed if:

135

• The summary effect measure were relative risk rather than Peto odds ratio

• Eligibility were restricted to studies without high risk of bias

• Eligibility were restricted to fully published studies

Overall quality of the body of evidence: Summary of Findings Table

We prepared a 'Summary of findings' table using Guideline Development Tool software. This

table evaluated the overall quality of the body of evidence for the three review outcomes

using GRADE criteria (study limitations (i.e. risk of bias), consistency of effect, imprecision,

indirectness and publication bias). Judgments about evidence quality (high, moderate or low)

were justified, documented, and incorporated into reporting of results for each outcome.

Results

Description of studies

Results of the search

2016 update: Two hundred and eighty-nine studies were retrieved by the search; a total of

124 duplicates were discarded, leaving 165 studies for screening of title and abstract. Two

new studies were identified concerning the infusion of mannitol (Saremi 2003) and calcium

gluconate (El-Khayat 2015). However, calcium gluconate has a very different

pathophysiological mechanism than the other IV fluids used, which all are volume expanders.

We excluded El-Khayat 2015. A discussion on this topic took place between the authors and

led to a decision to maintain a focus on volume expanders only; therefore, we amended the

protocol and changed the title accordingly. The data from Gokmen 2005 (conference

abstract) were excluded from this update of the review, as there was some concern that the

data overlapped with the Gokmen 2001 publication, which was published as a full paper. We

tried to contact the author to clarify potential duplication of data but did not succeed. In total,

nine studies were assessed for inclusion in this review (Figure 1).

2014 update: Two hundred and seventy-three records were retrieved by the search and

were screened. One unpublished study was deemed potentially eligible and was awaiting

classification. The rest were discarded as clearly ineligible based on the title or abstract.

Searches prior to 2014: In earlier versions of the review a total of 43 articles were identified

as potentially eligible and retrieved in full text. Of these, 34 articles (32 studies) were further

assessed and excluded. Eight studies (nine articles) were included.

136

Included studies: The nine included studies (n = 1867 women) were all single-centre

studies. Eight studies were parallel-group RCTs comparing a single intervention versus

placebo or a no treatment group; the Gokmen 2001 study had a three-armed design with two

different intervention groups versus placebo. Eight studies were published as full papers and

one as a 'letter to the editor' (Koike 1999).

Participants: Two studies used estradiol (E2) as the basic risk factor of ovarian

hyperstimulation syndrome (OHSS) (7000 pmol/L in Shoham 1994, 11,010 pmol/L in Isik

1996), both in combination with 'multifollicular response'; however no specific number of

follicles was mentioned. Two studies used the number of retrieved oocytes as the main risk

factor (Bellver 2003; Koike 1999). Four studies used both E2 level and number of follicles or

oocytes as inclusion criteria; high E2 or number of follicles on day of human chorionic

gonadotrophin (hCG) administration/number of retrieved oocytes in Gokmen 2001, Isikoglu

2007 and Konig 1998; high E2 level and number of follicles in Shalev 1995. Where E2 levels

were (partly) used to define the 'high-risk' population, cut-off levels varied (1906 pg/mL in

Shoham 1994, > 2506 pg/mL in Shalev 1995, > 3000 pg/mL in Gokmen 2001, > 1500 pg/mL

in Konig 1998, > 3000 pg/mL in Isik 1996, > 4000 pg/mL in Isikoglu 2007, > 9200 pg/mL in

Koike 1999 ; where necessary pmol/L was converted to pg/mL). One study included women

with polycystic ovary syndrome (PCOS) as their 'high-risk' group (Saremi 2003), without

taking E2 levels or number of follicles/oocytes into account. One study excluded women with

very high E2 levels and performed cycle cancellation for this extremely high-risk group for E2

> 7000 pmol/L (Shoham 1994). Mean female age was around 30 years in all studies (mean

age range was 27.5 to 32.6 years). The intervention and control groups were largely similar

regarding the number of ampoules of human menopausal gonadotropin (hMG) used for

controlled ovarian hyperstimulation, number of oocytes retrieved and number of embryos.

However, in five studies (Bellver 2003; Gokmen 2001; Koike 1999; Shalev 1995; Saremi

2003), there was no mention of the number of ampoules between intervention and control

group.

Interventions: Seven studies compared albumin versus placebo (Gokmen 2001; Isikoglu

2007; Koike 1999; Shoham 1994) or no treatment (Bellver 2003; Isik 1996; Shalev 1995).

Two studies compared hydroxyethyl starch (HES) versus placebo (Gokmen 2001; Konig

1998). One study made both comparisons (Gokmen 2001). One study compared mannitol

versus no treatment (Saremi 2003). Placebo (saline) was used in the control group of five

studies (Gokmen 2001; Isikoglu 2007; Koike 1999; Konig 1998; Shoham 1994).

137

Figure 1; Flow diagram for meta-analysis. Identification and selection of publications

138

The dose and timing of the interventions varied between studies but all were given in a

relatively early phase (i.e. day of hCG administration or oocyte retrieval) to try to prevent

early onset OHSS: Shoham 1994 used 50 g albumin two hours before oocyte retrieval; Koike

1999 used 37.5 g albumin just after oocyte retrieval; Shalev 1995 used 20 g albumin just

after oocyte retrieval; and Isik 1996 used 10 g albumin two hours before oocyte retrieval;

Gokmen 2001 and Isikoglu 2007 used 10 g albumin immediately after oocyte retrieval; and

Bellver 2003 used 40 g of albumin immediately after oocyte retrieval. In Gokmen 2001, 6%

hydroxyethyl starch (200/0.5) (500 mL) was used immediately after oocyte retrieval, and in

Konig 1998 it was used 48 hours after the oocyte retrieval. Saremi 2003 used mannitol 3

g/kg bodyweight daily infusions (each 100 mL infusion containing 20 g mannitol and water for

injection), starting the day after hCG injection until the third day after embryo transfer (lasting

five to seven days depending on day of embryo transfer).

Outcomes: All nine studies reported the incidence of severe OHSS and five studies

additionally reported on the incidence of moderate OHSS (Bellver 2003; Gokmen 2001; Isik

1996; Konig 1998; Saremi 2003). Diagnosis of severity of OHSS was done according to the

criteria of Schenker 1978 in three studies (Gokmen 2001; Isik 1996; Shoham 1994), while

Shalev 1995 and Isikoglu 2007 used the criteria of Navot 1988, Bellver 2003 used the criteria

of Golan 1989, and Koike 1999 used those of Ben-Rafael 1995. Konig 1998 used the criteria

of WHO 1973. Saremi 2003 did not explicitly state the reference but describes criteria similar

to Golan 1989.

Eight studies reported pregnancy rates. Diagnosis of pregnancy was determined using

serum ß-hCG in all studies except Isikoglu 2007 and Saremi 2003, which used "presence at

ultrasound of a gestational sac with positive fetal heart rate". Most studies mentioned

adverse events in their results or discussion sections, but none of the studies prespecified

adverse events as an outcome, or reported comparative data on adverse effects in all study

groups.

Excluded studies: We excluded 349 studies which did not meet the inclusion criteria for this

review, in most cases because they did not make any comparisons of interest or were not

randomised.

Risk of bias in included studies

Allocation (selection bias)

Sequence generation: Seven studies used adequate methods of sequence generation and

were rated as at low risk of bias (Bellver 2003; Gokmen 2001; Isik 1996; Koike 1999; Konig

139

1998; Saremi 2003; Shalev 1995). Two studies did not report details of the methods used

and were rated as at unclear risk of bias (Isikoglu 2007; Shoham 1994).

Allocation concealment: None of the studies clearly described an acceptable method of

allocation concealment and all were rated as at unclear risk of bias in this domain.

Blinding (performance bias and detection bias): We considered that lack of blinding might

influence outcome assessment for the outcomes of OHSS and adverse events. One study

clearly blinded both participants and outcomes assessors, and was rated as at low risk of

bias (Isikoglu 2007). One study stated that "physicians were blinded to the allocated groups

and a nurse performed the protocol" (Saremi 2003), and we considered this study also to be

at low risk of bias. Four studies did not mention blinding, and were rated as at unclear risk

(Gokmen 2001; Koike 1999; Konig 1998; Shoham 1994). Three studies were unblinded and

were rated as at high risk of bias (Bellver 2003; Isik 1996; Shalev 1995)

Incomplete outcome data (attrition bias): All studies appeared to include all randomised

women in analysis. All were rated as at low risk of attrition bias apart from one (Gokmen

2001). An abstract from a conference held in 2005 (Gokmen 2005) appears to relate to the

same study but has a larger sample size and reports two additional events. We attempted to

contact the study authors to query this but did not receive a reply. We therefore rated this

study as at unclear risk of attrition bias.

Selective reporting (reporting bias): Although most studies either stated that no events

were observed, or mentioned events in one or both arms, it was unclear whether data on

adverse events were collected prospectively or systematically. All studies were rated as at

unclear risk of bias in this domain.

Other potential sources of bias: No other potential source of bias was identified in any of

the studies, and they were rated as at low risk in this domain.

Effects of interventions

Intravenous (IV) fluids versus no treatment or placebo

Primary outcome

Human albumin versus placebo or no treatment

Seven studies compared albumin versus placebo (Gokmen 2001;Isikoglu 2007; Koike 1999;

Shoham 1994) or no treatment (Bellver 2003; Isik 1996; Shalev 1995).

140

Moderate or severe OHSS: There was evidence of a difference between the groups, though

(Peto OR 0.67 95% CI 0.47 to 0.95, seven studies, 1452 women; I² = 69%, very low quality

evidence). Heterogeneity was substantial, and there was no obvious explanation for this.

This suggests that if the rate of moderate or severe OHSS with no treatment is 12%, it will be

about 9% (6% to 12%) with the use of intravenous albumin. (Figure 2)

Subgroup and sensitivity analyses: Subgroup analysis showed no evidence that findings

differed in studies that only reported severe OHSS (test for subgroup differences: Chi² =

0.19, df = 1 (P = 0.66), I² = 0%).Use of a risk ratio reduced heterogenity to I2=57%.

Sensitivity analysis by study risk of bias was not possible as no studies were at low risk of

bias in most domains.

Live birth: None of the studies reported live birth as an outcome.

Pregnancy: Seven studies reported data for this outcome. There was evidence of a

detrimental effect on pregnancy rates for the use of albumin (PetoOR 0.72 95%CI 0.55 to

0.94, I² = 42%, seven studies, 1069 women, moderate quality evidence)

Subgroup analysis: We examined whether effects differed according to the method used

for diagnosing pregnancy (by _-hCG: Gokmen 2001; Isik 1996; Koike 1999; Shalev 1995;

Shoham 1994) or heartbeat on ultrasound (Bellver 2003 (only pregnancy data for autologous

cycles considered); Isikoglu 2007) and found no evidence of a difference between the

subgroups (test for subgroup differences: Chi² = 0.78, df = 1 (P = 0.38), I² = 0%.

Adverse effects None of the studies explicitly mentioned ’adverse effects’ as a prespecified

outcome, though most commented (in the results or discussion section) on adverse events

related to the interventions. Among women receiving albumin, in one study (Gokmen 2001),

a woman developed an anaphylactoid reaction with hypotension and laryngospasm. In a

second study (Isik 1996), two women developed mild urticaria. Four studies (Bellver 2003,

Isikoglu 2007, Shalev 1995, Shoham 1994), noted that no side effects or hypersensitivity

reactions were detected in association with the intervention. Koike 1999 did not mention

adverse effects

Hydroxyethyl starch (HES) versus placebo or no treatment

Two studies compared hydroxyethyl starch (HES) versus placebo (Gokmen 2001; Konig

1998). Both reported overall rates ofmoderate or severe OHSS.

141

Moderate or severe OHSS: There was evidence of a beneficial effect of HES on OHSS

(Peto OR 0.27 95% CI 0.12 to 0.59, I² = 0%, two studies, 272 women, very low quality

evidence). This suggests that if the rate of moderate or severe OHSS with no treatment is

16%, it will be about 5% (2% to 10%) with the use of HES. (Figure 3)

Sensitivity analysis: Use of a risk ratio did not materially change the main findings.

Sensitivity analysis by study risk of bias was not possible as neither studies was at low risk of

bias in most domains.

Live birth: Neither of the studies reported live birth as an outcome.

Pregnancy: There was no evidence of a difference in pregnancy rates (diagnosed by serum

β-hCG level) between women receiving IV HES and those receiving placebo (Peto OR 1.20

95% CI 0.49 to 2.93, one study, 168 women, very low quality evidence

Adverse effects: Neither of the studies explicitly mentioned ’adverse effects’ as a

prespecified outcome. There were two mild cases of urticaria in one study (Gokmen 2001)

and one case of urticaria in the other (Konig 1998).

Mannitol versus placebo or no treatment

One study compared mannitol versus no treatment (Saremi 2003).This study reported overall

rates of moderate or severe OHSS.

Moderate or severe OHSS: There was evidence of a beneficial effect of mannitol on OHSS

(Peto OR 0.38, 95% CI 0.22 to 0.64, one study, 226 women, low quality evidence). This

suggests that if the rate of OHSS with no treatment is 52%, it will be about 29% (19% to

41%) with mannitol

Sensitivity analysis: Use of a risk ratio did not materially change the main findings.

Live birth: Live birth was not reported as an outcome.

Pregnancy: There was no evidence of a difference in pregnancy rates (diagnosed by

ultrasound) between the groups (Peto OR 0.85 95% CI 0.85 to 1.55; one study, 226 women,

low quality evidence)

Adverse effects: Adverse events were not mentioned in this study. In private

correspondence the authors stated that data on adverse events were collected, but they did

not specify what type or report any events.

142

Figu

re 2

:For

est p

lot f

or m

oder

ate

to s

ever

eO

HSS

inci

denc

e pe

r wom

en ra

ndom

ised

143

Figu

re 3

:For

est p

lot f

or m

oder

ate

to s

ever

e O

HSS

per

wom

en ra

ndom

ised

144

Discussion

Nine randomised controlled studies compared the effectiveness of intravenous (IV)

administration of the volume expanders human albumin, hydroxyethyl starch (HES), or

mannitol versus placebo or no treatment for the prevention of ovarian hyperstimulation

syndrome (OHSS) in women at high risk of OHSS. The overall quality of the evidence ranged

from very low to moderate. There was evidence that intravenous albumin administration

around the time of oocyte retrieval has a beneficial effect on the incidence of moderate or

severe OHSS. However, there was substantial unexplained heterogeneity between studies

for this outcome (I² = 69%). Our analysis suggested thatHESmight be associated with

reduced rates of moderate or severe OHSS, but this was only based on two studies reporting

only 28 events. Mannitol also appeared to have a beneficial effect on the incidence of OHSS,

but this finding was based on a single study, so this moderate quality evidence remains to be

confirmed in additional, large RCTs. Live birth rate was not reported in any of the

studies.There was moderate quality evidence that administration of human albumin lowered

pregnancy rates in women at high risk for OHSS. For HES or mannitol there was no

evidence of an effect on pregnancy rates. Adverse effectswere poorly reported and no

firmconclusions could be drawn; although uncommon, clinicians should be aware that

administration of IV fluids could cause severe morbidity.

There were no randomised controlled studies (RCTs) that compared other volume expanders

such as dextran or polygeline versus placebo or no treatment. There was significant clinical

heterogeneity between the included studies. The criteria for selecting women with a risk of

OHSS varied across trials. Some used the number of oocytes at the day of hCG

administration or the number of retrieved oocytes. Other studies used E2 level as a basic

riskmarker, but cut-off levels varied greatly amongst studies; for example, inclusion E2 level

for the study matched cycle cancellation (and therefore exclusion level) in another study. The

method or criteria of OHSS diagnosis also varied widely between studies. With regard to

studies of human albumin, the dosage of gonadotropins used for controlled ovarian

hyperstimulation was not stated in most of the studies; the dose and timing of administration

of albumin or starch varied between studies, between 10 g albumin immediately after oocyte

retrieval to 50 g albumin one or two hour before oocyte retrieval, whilst 52.5 g albumin is

required to accomplish a normal plasma albumin level of 4.2 to 4.5 g/100 mL in a well-

hydrated patient (Kissler 2001).

All of the plasma expanders were given either on the day of hCG administration or day of

oocyte retrieval, therefore implicitly aiming to prevent early onset OHSS. The included

studies made no distinction between early and late onset OHSS.

145

All the studies were at serious risk of bias: none adequately described their method of

allocation concealment, none prospectively collected comparative data on adverse events

and only one clearly reported blinded outcome assessment. The quality of the evidence was

rated as very low to moderate for all comparisons. The main limitations in the evidence were

risk of bias, statistical heterogeneity, imprecision, and lack of data for most comparisons.

Previous versions of the review included both Gokmen 2001 and a subsequent study by the

same group (Gokmen 2005).We understand from personal communication with Christos

Venetis (first author of Venetis 2011) that these two studies overlap and so we have removed

the data for Gokmen 2005 from this updated version of the review. However, we have been

unable to contact the study authors directly. No other potential biases were identified in the

review process.

Two older systematic reviews of human albumin for the prevention of OHSS reached slightly

different conclusions, but both focused on severe OHSS only. Both reviews reported no

difference in the occurrence of severe OHSS between those who received intravenous

albumin and those who did not (Venetis 2011: odds ratio (OR) 0.80; 95%confidence interval

(CI), 0.52 to 1.22, eight RCTs, 1199 women; Jee 2010: risk ratio (RR) 0.80, 95% CI 0.57

to1.12, 9 RCTs, 1613 women). These reviews however included quasi-randomised studies

which were not eligible for the current review (for Jee 2010 this was Panay 1999; for Venetis

2011 this was Ben-Chetrit 2001) and Venetis 2011 also included data from Gokmen 2005

that we considered possibly biased. The slightly deleterious effect of albumin on pregnancy

rate reported by Jee 2010 was confirmed in our review. We have not identified any other

systematic reviews comparing HES or mannitol with placebo or no treatment for prevention

of OHSS.


Implications for practice

Evidence suggests that the plasma expanders assessed in this review (human albumin, HES

and mannitol) reduce rates of moderate and severe OHSS in women at high risk. Adverse

events appear to be uncommon, but were too poorly reported to reach any firm conclusions,

and there were no data on live birth. However, there was evidence that human albumin

reduces pregnancy rates. While there was no evidence that HES, or mannitol had any

influence on pregnancy rates, the evidence of effectiveness was based on very few trials

which need to be confirmed in additional, larger randomised controlled trials (RCTs) before

they should be considered for routine use in clinical practice.Implications for research

146

High-quality, well-designed and adequately powered RCTs are needed to assess the

effectiveness of volume expanders in women at high risk of developing OHSS. Future

studies should take into consideration the costeffectiveness and psychological impact of

treatment with volume expanders and should systematically report on adverse events.

Acknowledgements

Dr Saremi is acknowledged for providing additional information on his publication. Special

thanks also to the highly supportive team at the Cochrane office in Auckland, especially

editor Jane Marjoribanks and the Information Specialist Marian Showell for designing and

running the search strategies. We thank Professor Johannes Evers, Professor Hesham Al-

Inany and Professor Mohamed Aboulghar for their contributions to previous versions of this

review. Professor Al-Inany took the lead in writing the protocol and the first version of the full

review. Prof Aboulghar screened studies and extracted and interpreted data in the first

version of the full review.

147

References

Included studies • Bellver J, Munoz EA, Ballesteros A, Soares SR, Bosch E, Simon C, et al. Intravenous

albumin does not prevent moderate–severe ovarian hyperstimulation syndrome in high-risk IVF patients: a randomized controlled study. Human Reproduction 2003;18(11):2283–8.

• Gokmen O, Ugur M, Ekin M, Keles G, Turan C, Oral H. Intravenous albumin versus hydroxyethyl starch for the prevention of ovarian hyperstimulation in an in-vitro fertilization programme: a prospective randomised placebo controlled study. European Journal of Obstetrics, Gynecology, and Reproductive Biology 2001;96(2):187-92.

• Isik AZ, Gokmen O, Zeyneloglu HB, Kara S, Keles G, Gulekli B. Intravenous albumin prevents moderate-severe ovarian hyperstimulation in in vitro fertilisation patients: a prospective randomized and controlled study. European Journal of Obstetrics, Gynecology, and Reproductive Biology 1996; 70:170-83.

• Isikoglu M, Berkkanoglu M, Senturk Z, Ozgur K. Human albumin does not prevent ovarian hyperstimulation syndrome in assisted reproductive technology program: a prospective randomized placebo-controlled double blind study. Fertility and Sterility 2007; 88(4):982-5.

• Koike E, Araki S, Ogawa S, Minakami H, Sato I. Does i.v albumin prevent ovarian hyperstimulation syndrome? Human Reproduction 1999; 14(7):1920.

• Konig E, Bussen S, Sütterlin M, Steck T. Prophylactic intravenous hydroxyethyle starch solution prevents moderate-severe ovarian hyperstimulation in in-vitro fertilization patients: a prospective, randomized, double-blind and placebo-controlled study. Human Reproduction 1998; 13(9):2421-4.

• Saremi A, Alam M, Motaghi M. Administration of mannitol to prevent severe ovarian hyperstimulation syndrome: A randomized controlled trial. Middle East Fertility Society Journal 2003; 8(2):159-163.

• Shalev E, Giladi Y, Matilsky M, Ben-Ami M. Decreased incidence of severe ovarian hyperstimulation syndrome in high risk in-vitro fertilisation patients receiving intravenous albumin: a prospective study. Human Reproduction 1995; 10:1373-6.

• Shoham Z, Weissman A, Barash A, Borenstein R, Schachter M, Insler V. Intravenous albumin for the prevention of severe ovarian hyperstimulation syndrome in an invitro fertilisation program: a prospective, randomised, placebo-controlled study. Fertility and Sterility 1994; 62:137-42.

Excluded studies • Abramov Y, Fatum M, Abrahamove D, Schenker JC. Hydroxyethyl starch versus

human albumin for the treatment of severe ovarian hyperstimulation syndrome: a preliminary report. Fertility and Sterility 2001; 75:1228-30.

148

• Abramov Y, Fatum M, Fasouliotis S, Abrahamov D, Schenker JC. Hydroxyethylstarch versus human albumin for the treatment of severe ovarian hyperstimulation syndrome. Fertility and Sterility. Abstracts of the 17th Annual meeting of the ESHRE 2001; 16(1):121. [

• Abuzeid M, Abed S, Salem W, Joseph S, Ashraf M, Rizk P.B. The effectiveness of 6% hydroxyethyle starch solution in reducing the incidence of severe hyperstimulation syndrome in polycystic ovarian disease patients: A prospective cohort clinical trial. Journal of Reproductive Medicine and Endocrinology, IFFS 2010 September 12-16 Munich; 7(4):240-383.

• Ahmadi Sh, Rahmani E, Oskouian H. Cabergoline versus human albumin in prophylaxis ovarian hyperstimulation syndrome. Reproductive BioMedicine Online 2010; Suppl. 3:S41–S42.

• Asch R, Ivery G, Goldsman M. The use of intravenous albumin in patients at high risk for severe ovarian hyperstimulation syndrome. Human Reproduction 1993; 8:1015-20.

• Ben Chetrit A, Eldar-Geva T, Gal M, Huerta M, Mimon T, Algur N, et al. The questionable use of albumin for the prevention of ovarian hyperstimulation syndrome in an IVF programme: a randomized placebo-controlled trial. Human Reproduction 2001; 16(9):1880-4.

• Ben-Rafael Z, Orvieto R, Dekel A, Peleg D, Gruzman C. Intravenous albumin and the prevention of severe ovarian hyperstimulation syndrome. Human Reproduction 1995;10(10):2750-2.

• Cambiaghi AS, Castellotti DS. Oral whey protein for preventing ovarian hyperstimulation syndrome. Fertility and Sterility. Abstracts from the annual meeting of ASRM 84 Suppl 1; 84(1):315.

• Chen C, Chen S, Wu M, Ho H, Yang J, Yang Y. Intravenous albumin does not prevent the development of severe ovarian hyperstimulation syndrome. Fertility and Sterility 1997; 68:287-91.

• Chen CD, Chao KH, Yang JH, Chen SU, Ho HN, Yang YS. Comparison of coasting and intravenous albumin in the prevention of ovarian hyperstimulation syndrome. Fertility and Sterility 2003; 80(1):86-90.

• Costabile L, Unfer V, Manna C, Gerli S, Rossetti D, Di Renzo GC. Use of intramuscular progesterone versus intravenous albumin for the prevention of ovarian hyperstimulation syndrome. Gynecologic and Obstetric Investigation 2000; 50(3):182-5.

• Dmitrieva NV, Yakovenko SA, Zorina IV, Voznesenskaya YV, Apryshko VP. Comparison of calcium gluconate and starch solution in the treatment of ovarian hyperstimulation syndrome. Reproductive BioMedicine Online 2010; 3:S41–S42.

• Egbase PE, Makhseed M, Al Sharhan M, Grdzinskas JG. Timed unilateral ovarian follicular aspiration prior to administration of human chorionic gonadotrophin for the

149

prevention of severe ovarian hyperstimulation syndrome in in vitro fertilisation: a prospective randomised study. Human Reproduction 1997; 12:2603-6.

• El-Khayat W, Elsadek M. Calcium infusion for the prevention of ovarian hyperstimulation syndrome: a double-blind randomized controlled trial. Fertility and Sterility 2015; 103(1):101-5.

• Endo T, Kitajima Y, Hayashi T, Fujii M, Hata H, Azumaguchi A. Low-molecular-weight dextran infusion is more effective for the treatment of hemoconcentration due to severe ovarian hyperstimulation syndrome than human albumin infusion. Fertility and Sterility 2004; 82(5):1449-51.

• Fan YH, Qiao J, Chen XN, Wang HY, Ma CH, Liu P. Assisted reproductive Intravenous hydroxyethyl starch versus human albumin for prevention of the ovarian hyperstimulation syndrome. VIII FIGO World Congress of Gynecology and Obstetrics 2006; 2:34.

• Fan YH, Qiao J, Chen XN, Wang HY, Ma CH, Liu P. Intravenous hydroxyethyl starch versus human albumin for prevention of the ovarian hyperstimulation syndrome. Fertility and Sterility 2006; 86 Suppl 2:136.

• Fluker MR, Copeland JE, Yuzpe AA. An ounce of prevention: outpatient management of the ovarian hyperstimulation syndrome. Fertility and Sterility 2000; 73(4):821-4.

• Gamzu R, Almog B , Levin Y, Avni A, Lessing BJ, Baram A. Comparative efficacy of hydroxyethyl starch and Haemaccel for the treatment of severe ovarianhyperstimulation syndrome. Fertility and Sterility 2002; 77(6):1302-3.

• Gokmen O, Ozcan S, Erman Akar M, Ugur M. A randomized prospective placebo-controlled study of intravenous albumin vs. hydroxyethyl starch for the prevention of ovarian hyperstimulation in an in-vitro fertilization programme. Fertility and Sterility: Abstracts of ASRM 2005; 84(Suppl 1):308.

• Graf AM, Fischer R, Naether ONJ, Baukloh V, Tafel J, Nuckel M. Reduced incidence of ovarian hyperstimulation syndrome by prophylactic infusion of hydroxyethyl starch solution in an in-vitro fertilization programme. Human Reproduction 1997;12(12):2599-602.

• Halme J, Toma SK, Talbert LM. A case of severe ovarian hyperstimulation in a healthy oocyte donor. Fertility and Sterility 1995; 64(4):857-9.

• Isik AZ, Ozgun OD, Kahraman S, Polat G, Vicdan K, Biberoglu K, et al. Intravenous albumin combined with low dose human chorionic gonadotrophin and late step-down administration of menotropins are effective in prevention of severe ovarian hyperstimulation syndrome in high-risk patients in an in vitro fertilisation program. Middle East Fertility Society Journal 1997; 2/3:238-42.

• Isik AZ, Vicdan K. Combined approach as an effective method in the prevention of severe ovarian hyperstimulation syndrome. European Journal of Obstetrics, Gynecology, and Reproductive Biology 2001; 97(2):208-12.

150

• Kissler S, Neidhardt B, Siebzehnrübl E, Schmitt H, Tschaikowsky K, Wildt L. The detrimental role of colloidal volume substitutes in severe ovarian hyperstimulation syndrome: a case report. European Journal of Obstetrics, Gynecology, and Reproductive Biology 2001; 99(1):131-4.

• Koike E, Araki S, Ogawa S, Minakami H, Sayama H, Shibahara H, et al. Clinical efficacy of peritoneovenous shunting for the treatment of sever ovarian hyperstimulation syndrome. Human Reproduction 2000; 15(1):113-7.

• Kumbak B, Kahraman S, Karlikaya G, Karagozoglu H, Sen T, Hatirnaz S. Intravenous albumin prophylaxis in high risk patients for moderate to severe ovarian hyperstimulation syndrome. Fertility and Sterility 2005; 84 Suppl (1):264.

• Lewit N, Kol S, Ronen N, Itskovitz-Eldor J. Does intravenous administration of human albumin prevent severe ovarian hyperstimulation syndrome? Fertility and Sterility 1996; 66(4):654-6.

• Lincoln SR, Opsahl MS, Blauer KL, Black SH, Schulman JD. Aggressive outpatient treatment of ovarian hyperstimulation syndrome with ascites using transvaginal culdocentesis and intravenous albumin minimizes hospitalization. Journal of Assisted Reproduction and Genetics 2002; 19:159-63.

• Matorras R, Andrés M, Mendoza R, Prieto B, Pijoan JI, Expósito A. Prevention of ovarian hyperstimulation syndrome in GnRH agonist IVF cycles in moderate risk patients: randomized study comparing hydroxyethyl starch versus cabergoline and hydroxyethyl starch. European Journal of Obstetrics Gynecology and Reproductive Biology 2013; 170(2):439-43.

• Milacic D, Radonjic G, Matijasevic S, Kontic O. Prevention of ovarian hyperstimulation syndrome with iv albumin. Human Reproduction 1996; 11(1):216.

• Mukherjee T, Copperman AB, Sandler B, Bustillo M, Grunfeld L. Severe ovarian hyperstimulation despite prophylactic albumin at the time of oocyte retrieval for in vitro fertilization and embryo transfer. Fertility and Sterility 1995; 64(3):641-3.

• Naredi N, Karunakaran S. Calcium gluconate infusion is as effective as the vascular endothelial growth factor antagonist cabergoline for the prevention of ovarian hyperstimulation syndrome. Journal of Human Reproductive Sciences 2013;6(4):248-52.

• Ndukwe G, Thornton S, Fishel S, Dowell K, Aloum M. Severe ovarian hyperstimulation syndrome: is it really preventable by prophylactic intravenous albumin? Fertility and Sterility 1997; 68(5):851-4.

• Ng E, Leader A, Claman P, Domingo M, Spence JEH. Intravenous albumin does not prevent the development of severe ovarian hyperstimulation syndrome in an in-vitro fertilization programme. Human Reproduction 1995; 10(4):807-10.

• Iammarone E, Panay N, ZosmerA, TozerA, Hussain S, Wilson C, et al. Does the prophylactic use of intravenous albumin prevent ovarian hyperstimulation syndrome? A randomised prospective study. Human Fertility 1999; 2(2):179-180.

151

• Panay NA, Iammorrone E, Zosmer A, Tozer A, Hussain S. Does the prophylactic use of intravenous albumin prevent ovarian hyperstimulation syndrome? A randomized prospective study. Abstracts from the 15th Annual Meeting of the ESHRE, Tours, France 1999; 14:105.

• Shaker AG, Zosmer A, Dean N, Berik JS, Jacob HS, Tan SL. Comparison of intravenous albumin and transfer of fresh embryos with cryopreservation of all embryos for subsequent transfer in prevention of ovarian of ovarian hyperstimulation syndrome. Fertility and Sterility 1996; 65:992-6.

• Tan Sl, Balen A, El Hussein E, Campbell S, Jacobs HS. The administration of glucocorticoids for the prevention of ovarian hyperstimulation syndrome in invitro fertilisation: a prospective randomised study. Fertility and Sterility 1992; 58:378-83.

• Tehraninejad E, Hafezi M, Arabipoor A, Aziminekoo E, Chehrazi M, Bahmanabadi A. Comparison of cabergoline and intravenous albumin in the prevention of ovarian hyperstimulation syndrome: a randomized clinical trial.. Journal of Assisted Reproduction & Genetics. 2012; 29(3):259-64.

• Torabizadeh A, Vahidroodsari F, Ghorbanpour Z. Comparison of albumin and cabergoline in the prevention of ovarian hyperstimulation syndrome: A clinical trial study. Iranian Journal of Reproductive Medicine 2013; 11(10):837-42.

• Yakovenko SA, Zorina IV, Dmitrieva NV, Troshina MN, Apryshko VP, Voznesenskaya JV. Intravenous administration of calcium in ovarian hyperstimulation syndrome (OHSS) prevention. European Journal of Obstetrics Gynecology and Reproductive Biology 2011; 1:s20.


• Aboulghar MA, Mansour RT. Ovarian hyperstimulation syndrome: classifications and critical analysis of preventive measures. Human Reproduction Update 2003;9(3):275-89.

• Cerrillo M, Pacheco A, Rodríguez S, Mayoral M, Ruiz M, García Velasco JA. Differential regulation of VEGF, Cadherin, and Angiopietin 2 by trigger oocyte maturation with GnRHa vs hCG in donors: try to explain the lower OHSS incidence. Abstracts of the 25th annual meeting of the ESHRE 2009; 24(1):i60.

• Chen D, Burmeister L, Goldschlag D, Rosenwaks Z. Ovarian hyperstimulation syndrome: strategies for prevention. Reproductive Biomedicine Online 2003; 7(1):43-9.

• D'Angelo A, Amso NN. Embryo freezing for preventing ovarian hyperstimulation syndrome. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD002806.

• D'Angelo A, Brown J, Amso NN. Coasting (withholding gonadotrophins) for preventing ovarian hyperstimulation syndrome. Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD002811.

152

• Delvigne A, Rozenberg S. Epidemiology and prevention of ovarian hyperstimulation syndrome (OHSS): a review. Human Reproduction Update 2002; 8:559-77.

• Edwards RG. IVF, IVM, natural cycle IVF, minimal stimulation IVF - time for a rethink. Reproductive Biomedicine Online 2007; 15:106-19.

• Egbase PE. Severe OHSS: how many cases are preventable? Human Reproduction 2000; 15:8-10.

• Engmann L, DiLugie A, Schmidt D, Nulsen J, Maier D, Benavida C. The use of gonadotropin-releasing hormone (GnRH) agonist to induce oocyte maturation after cotreatment with GnRH antagonist in high-risk patients undergoing in vitro fertilization prevents the risk of ovarian hyperstimulation syndrome: a prospective randomised controlled study. Fertility and Sterility 2008; 89(1):84-91.

• Enskog A, Nilsson L, Brännström M. Plasma levels of free vascular endothelial growth factor(165) (VEGF(165)) are not elevated during gonadotropin stimulation in in vitro fertilization (IVF) patients developing ovarian hyperstimulation syndrome (OHSS): results of a prospective cohort study with matched controls. European Journal of Obstetrics, Gynecology, and Reproductive Biology 2001; 96:196-201.

• Foong LC, Bhagavath BA, Kumar J, Ng SC. Ovarian hyperstimulation syndrome is associated with reversible impairment of vascular reactivity. Fertility and Sterility 2002; 78(6):1159-63.

• Garcia-Velasco JA, Pellicer A. New concepts in the understanding of the ovarian hyperstimulation syndrome. Current Opinion in Obstetrics and Gynecology 2003;15(3):251-6.

• Gokmen O, Ozcan S, Erman Akar M, Ugur M. A randomized prospective placebo-controlled study of intravenous albumin vs. hydroxyethyl starch for the prevention of ovarian hyperstimulation in an in-vitro fertilization programme. .. Fertility and Sterility: Abstracts of ASRM 2005; 84 Suppl 1:308.

• Golan A, Ron-el R, Herman A, Soffer Y, Weinraub Z, Caspi. Ovarian hyperstimulation syndrome: an update review. Obstetrical & Gynecological Survey 1989; 44(6):430-40.

• Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration 2011;Available from www.cochrane-handbook.org.

• Humaidan P, Quartarolo J, Papanikolaou EG. . Preventing ovarian hyperstimulation syndrome: guidance for the clinician. . Fertility and Sterility 2010; 94:389–400.

• Jee BC, Suh CS, Kim YB, Kim SH, Choi YM, Kim JG, Moon SY. Administration of intravenous albumin around the time of oocyte retrieval reduces pregnancy rate without preventing ovarian hyperstimulation syndrome: a systematic review and meta-analysis. Gynecol Obstet Invest 2010; 70(1):47-54.

153

• Kol S, Solt I. GnRH agonist for triggering final oocyte maturation in patients at risk of ovarian hyperstimulation syndrome: still a controversy? Journal of Assisted Reproduction and Genetics 2008; 25:63-6.

• Loutradis D, Kiapekou E, Zapanti E, Antsaklis A. Oocyte maturation in assisted reproductive techniques. Annals of the New York Academy of Sciences 2006;1092:235-46.

• Mathur RS, Jenkins JM. Is ovarian hyperstimulation syndrome associated with a poor obstetric outcome? BJOG 2000; 107:943-6.

• McClelland DB. Human albumin solutions. BMJ 1990; 300:35-57.

• Navot D, Relou A, Birkenfeld A, Rabinowitz R, Brzezinski A, Margalioth EJ. Risk factors and prognostic variables in the ovarian hyperstimulation syndrome. American Journal of Obstetrics and Gynecology 1988; 159:210-5.

• Navot D, Bergh PA, Laufer N. Ovarian hyperstimulation syndrome in novel reproductive technologies: prevention and treatment. . Fertility & Sterility 1992;58:249-61.

• Rizk B, Aboulghar M, Smitz J, Ron-El R. The role of vascular endothelial growth factor and interleukins in the pathogenesis of severe ovarian hyperstimulation syndrome. Human Reproduction Update 1997; 3:255-6.

• Rizk, B and Aboulghar, M.A. Classification, pathophysiology and management of ovarian hyperstimulation syndrome. . In Brinsden, P. (ed.) In-Vitro Fertilization and Assisted Reproduction. The ParthenonPublishing Group, New York, London, 1999;pp. 131±155.

• Schenker JG, Weinstein D. Ovarian hyperstimulation syndrome: a current survey. Fertility and Sterility 1978; 30:225-68.

• Shawkat H, Westwood M, Mortimer A. Mannitol: a review of its clinical uses. Contin Educ Anaesth Crit Care Pain 2012; 12(2):82-85.

• Tang H, Hunter T, Hu Y, Zhai SD, Sheng X, Hart RJ. Cabergoline for preventing ovarian hyperstimulation syndrome. Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.: CD008605.

• Venetis CA, Kolibianakis EM, Toulis KA, Goulis DG, Papadimas I, Tarlatzis BC. Intravenous albumin administration for the prevention of severe ovarian hyperstimulation syndrome: a systematic review and metaanalysis. Fertil Steril. 2011;95(1):188-96.

• Vloeberghs V, Peeraer K, Pexsters A, D’Hooghe T. Ovarian hyperstimulation syndrome and complications of ART. Best Practice & Research. Clinical Obstetrics & Gynaecology 2009; 23(5):691-709.

• WHO. Agents stimulating gonadal function in human. World Health Organ Tech Rep Ser 1973; 514-20.

154

• Yan Z, Weich HA, Bernart W, Breckwoldt M, Neulen J. Ascular endothelial growth factor (VEGF) messenger ribonucleic acid (mRNA) expression in luteinized human granulosa cells in vitro. The Journal of Clinical Endocrinology and Metabolism 1993;77:1723-5.

• Youssef MA, Van der Veen F, Al-Inany HG, Mochtar MH, Griesinger G, Nagi Mohesen M, Aboulfoutouh I, van Wely MYoussef M, Van der Even F, Al-inany H, Griesinger G, Van Wely M. Gonadotropin-releasing hormone agonist versus HCG for oocyte triggering in antagonist ART cycles. A systematic review and meta-analysis. Cochrane Database Syst Rev.Abstracts of the 25th Annual Meeting of ESHRE, Amsterdam, Netherlands, 28 June-1 July 20142009; 1024(1):CD008046.

155

Chapter 7

Low doses of gonadotropins in IVF cycles for women with

poor ovarian reserve: Systematic review and meta-analysis

Youssef MA, van Wely M, Mochtar M, Fouda UM, van der Veen F

Submitted (under embargo)

156

Abstract

Study question: How does low dosing of gonadotropins and high doses of gonadotropins in

ovarian stimulation regimens compare in terms of ongoing pregnancy per fresh IVF attempt

in women with poor ovarian reserve?

Summary answer: We found no evidence of a difference in pregnancy outcomes between

low dosing of gonadotropins and high doses of gonadotropins in ovarian stimulation in

women with poor ovarian reserve and undergoing IVF/ICSI.

What is known already: Ovarian stimulation regimens for women with poor ovarian reserve

include high doses of gonadotropins combined with various protocols of GnRH analogues.

These regimens are of long duration, expensive and burdensome. Low dosing of

gonadotropins has been suggested as an alternative, either by reducing the dose of

gonadotropins itself or by a combination of gonadotropins and oral compounds such as

antiestrogens or aromatase inhibitors which shorten the duration of stimulation and thereby

lower the dose.

Study design, size, duration: A systematic review and meta-analysis of randomized

controlled studies that evaluate the effectiveness of low dosing of gonadotropins compared

to high doses of gonadotropins in women with poor ovarian reserve undergoing IVF/ICSI

treatment.

Participants/materials, setting, methods: We searched the PubMed, EMBASE, Web of

Science, the Cochrane Library and the Clinical Trials Registry using Medical Subject

Headings and free text terms up to June 2016, without language or year restrictions. We

included randomized controlled studies (RCTs) enrolling subfertile women with poor ovarian

reserve undergoing IVF/ICSI treatment and comparing low doses of gonadotropins versus

high doses of gonadotropins. We assessed the risk of bias using the criteria recommended

by the Cochrane Collaboration. We pooled the results by meta-analysis using the fixed and

random effects model. The primary outcome was ongoing pregnancy rate per woman

randomized.

Main results and the role of change: We retrieved 788 records. Fifteen RCTs (N=2183

women) were included in the analysis. Six studies (N=796 women) compared low doses of

gonadotropins versus high doses of gonadotropins. There was no evidence of a difference in

ongoing pregnancy rate (3 RCTs: RR 1.05, (95% CI 0.66 to 1.65), I2=0%). This suggests that

for a woman with a 13% chance of achieving an ongoing pregnancy with the use of high

doses of gonadotropins, the chance of an ongoing pregnancy with the use of low doses of

gonadotropins would be between 7% and 17%.

157

Nine studies (N= 1387 women) compared ovarian stimulation using gonadotropins combined

with the oral compounds letrozole (n=6), or clomiphene citrate (CC) (n=3) versus high doses

of gonadotropins. There was no evidence of a difference in ongoing pregnancy rate (3 RCTs:

RR 0.90, (95% CI: 0.63 to 1.27), I2=0%) This suggests that for a woman with a 13% chance

of achieving ongoing pregnancy with the use of high doses of gonadotropins, the chance of

an ongoing pregnancy with the use of gonadotropins combined with oral compounds would

be between 8% and 16%.

Limitations, reasonds for caution: Although we used strict inclusion criteria in the conduct

of the systematic review, the included studies had several methodological limitations and

clinical heterogeneity that have to be taken into account when interpreting the results.

Wider implications of the findings: We found no evidence of a difference in pregnancy

outcomes between low doses of gonadotropins and gonadotropins combined with oral

compounds compared to high doses of gonadotropins in ovarian stimulation regimens.

Whether the low doses of gonadotropins or gonadotropins combined with oral compounds is

to be preferred is unknown, as they have never been compared head to head. A health

economic analysis to test the hypothesis that an ovarian stimulation with low dosing is more

cost-effective than high doses of gonadotropins is needed.

Study funding/competing interest(s): None

Prospero registration number: CRD42016041301

Key words: low doses of gonadotropins /ovarian stimulation/ poor ovarian reserve/

randomized/ clomiphene citrate/ letrozole.

Introduction

The mean age of women giving birth to their first child is still rising, especially in Western

countries (Martin et al., 2009). As a result, more women face subfertility due to diminished

ovarian function who then seek medical help to become pregnant (te Velde and Pearson,

2002).

Older women are increasingly seeking and obtaining IVF and it is estimated that 37% of all

IVF cycles are performed in older women (Oudendijk et al., 2012; NICE guidelines 2013;

Kupka et al., 2014). Currently, the ovarian stimulation regimen for women with poor ovarian

reserve regardless of their age, includes high doses of gonadotropins - up to 600 IU/day-

combined with various protocols of GnRH analogues in an attempt to achieve high follicular

recruitment (Tarlatzis et al., 2003; Pandian et al., 2010; Masschaele et al., 2012; Bosdou et

al., 2012). Despite these high doses of gonadotropins, oocyte yield remains poor and

158

cancellation rates are high (Lekamge et al., 2008; Dercourt et al., 2016). This is due to a

patient factor which is completely unrelated to ovarian stimulation per se (Paulson et al.,

2016). At birth, both ovaries contain approximately one to two million primordial follicles, of

which only about 300,000 are available for ovulation at puberty. Thereafter, there is a steady

loss of follicles, at a rate of about 1000 per month, and this accelerates beyond 35 years of

age with a factor two (Faddy & Gosden 1995; Hansen et al., 2008).

Because there are at present no means for improving ovarian reserve, the question arises as

how to obtain the best possible outcome, with the least patient discomfort and lowest costs

while maintaining overall success rates in IVF. Over the years several mild ovarian

stimulation regimens have been suggested as alternatives for women with poor ovarian

reserve, aiming at reducing the dose of gonadotropins or shorten the duration of stimulation

using oral compounds such as antiestrogens or aromatase inhibitors (Nargund et al., 2007;

Yoo et al., 2011; Eftekhar et al., 2014; Ozcan et al., 2014). Striving for low doses of

gonadotropins in women with poor ovarian reserve is a valid approach for two reasons. First,

high doses have been shown not to be beneficial in women with poor ovarian reserve (Kim et

al. 2009). Second, high doses obviously increase the costs of IVF, a consequence that would

only be acceptable if paralleled by an improvement in IVF outcome. Oral compounds such as

clomiphene citrate (CC) have been used for decades as an adjunct to increase the pituitary

FSH secretion by reducing estrogen negative feedback (Clark & Markaverich 1981). The

alternative adjunct, aromatase inhibitors, inhibits the aromatase activity in granulosa cells

and thereby increases the intraovarian concentration of androgens by blocking the

aromatization to estrogen. The low estrogen then triggers the pituitary gland to an increase in

FSH release (Mitwally and Casper, 2002). Both mechanisms lead to a reduced required dose

of gonadotropins for stimulation.

There are six reviews that evaluated the treatment options for women with poor ovarian

reserve. The first review, including five studies published between 1989 and 2000 - without

pooling them - , evaluated increasing or decreasing the doses of gonadotropins with both

retrospective and prospective designs with parallel or historical controls (Tarlatzis et al.,

2003). The second review included two studies published in 1996 and 1999; one study

investigated natural cycle IVF with historical controls and the other study evaluated 225 IU

versus 450 IU of HMG in a retrospective cohort (Loutradis et al. 2007). The third review

assessed the effectiveness of high doses of FSH above 300 IU in a narrative way, and

included twenty-three studies, both retrospective and prospective with or without controls and

published between 1993 and 2004 (Siristatidis & Hamilton 2007). The fourth review included

just one study evaluating natural cycle IVF with zero doses of gonadotropins (Kyrou et al.,

2009). The fifth review evaluated various interventions in poor responders in 15 RCTs -

159

published between 1991 and 2008 -focusing mostly on pituitary down regulation (Pandian et

al., 2010). The final review assessed increasing the doses of gonadotropins in two studies

published in 2005 and 2008; one study was a randomized controlled study and the other a

retrospective cohort (Kamble et al., 2011). Evaluating all reviews, the conclusion is that there

is still insufficient evidence whether low doses of gonadotropins are a good alternative for

subfertile women with poor ovarian reserve undergoing IVF. We therefore designed this

systematic review and meta-analysis to evaluate the effectiveness of low doses of

gonadotropins in ovarian stimulation regimens in subfertile women with poor ovarian reserve

in comparison to high doses of gonadotropins in terms of ongoing pregnancy rate per fresh

IVF attempt.

Methods

Search strategy for identification of studies: We searched the following electronic

databases: MEDLINE, EMBASE, Web of Science, Cochrane library, and the Central Register

of Controlled Trials (http://clinicaltrials.gov/). covering the period until June 2016 based on

the following terms: GnRH antagonist, long GnRH agonist, oral compounds, clomiphene

citrate, letrozole, aromatase inhibitors, mild ovarian stimulation, minimal ovarian stimulation,

poor ovarian reserve, poor responders, GnRH analogues, GnRH agonist, natural cycle,

gonadotropins, low dose, high dose, pregnancy rate, number of oocytes, cancellation rate

“AND” IVF/ICSI/ART AND "randomized controlled trial(s)" OR " randomised controlled

trial(s)". We examined the reference lists of all known primary studies, review articles, citation

lists of relevant publications, abstracts of major scientific meetings (e.g. ESHRE and ASRM)

and included studies to identify additional relevant citations. If necessary, additional

information was sought from the authors. The search was not restricted by language. The

searches were conducted independently by YM and FU.

Selection of studies and data extraction

We included all parallel RCTs that recruited subfertile women characterized as having poor

ovarian reserve who had low or high doses of gonadotropins in IVF/ICSI treatment programs,

irrespective of the definition of poor ovarian reserve or response, and irrespective of the type

of gonadotropins or the type and protocol of GnRH analogues. We considered any

comparison between two different doses of gonadotropins and combinations of

gonadotropins with oral compounds to shorten the duration of stimulation and thereby

lowering the total dose of gonadotropins suitable for inclusion in our review. We defined low

doses as the range between 150-300 IU per day and high doses as the range between 450-

600 IU per day.

160

We selected the studies in a two-stage process. First, the titles and abstracts from the

electronic searches were scrutinized by two reviewers independently (YM and FU) and full

manuscripts of all citations that were likely to meet the predefined selection criteria were

obtained. Secondly, final inclusion or exclusion decisions were made on examination of the

full manuscripts. Any disagreements about inclusion were resolved by consensus or

arbitration by a third reviewer (FvdV and MvW).

We assessed the selected studies for methodological quality according to the criteria

recommended by the Cochrane Handbook (Higgins et al., 2001). We extracted the

Information on the adequacy of randomization, allocation concealment (selection bias),

blinding of participants and providers (performance bias), blinding of outcome assessor

(detection bias), incomplete outcome data (attrition bias), selective outcome reporting

(reporting bias) and other sources of bias such as sample size and funding. We extracted the

information on the type of GnRH analogue, starting dose of gonadotropins, dose adjustment,

type and dose of oral compounds. When needed, we wrote to the authors to try and retrieve

more data on more variables. From each study, outcome data were extracted in 2 X 2 tables.

Data extraction was performed in duplicate by YM and FU.

Definition of outcome measures for the meta-analysis

The main outcome measure was ongoing pregnancy, defined as a viable pregnancy of at

least 10-12 weeks of gestation, per randomized woman. Secondary outcome measures

included clinical pregnancy rate, live birth rate, duration of stimulation, total dose of

gonadotropins required for ovarian stimulation and cycle cancellation rate due to poor

ovarian response per randomized woman. Secondary outcomes that could be not expressed

per woman randomised were number of cumulus–oocytes complexes (COCs) retrieved,

number of metaphase II (MII) oocytes, number of embryos obtained, number of embryos

transferred, endometrial thickness on the day of hCG. These outcomes represent a unit of

analysis error and are therefore more prone to bias. We still report these outcomes, since

they enable clinicians to fully judge all clinical aspects of the interventions.


For each study, data on dichotomous outcomes were expressed as risk rate (RR) with 95%

confidence intervals (CIs). Relative risks were translated in to actual percentages to facilitate

the interpretation. Differences in continuous outcomes were analysed by calculating the

weighted mean differences (WMD) with 95% CI. Results were combined for meta-analysis

with Revman Software (Version 5.3, The Cochrane Collaboration, 2011). Study-to-study

variation was assessed by using the I2 statistic. A fixed effects model was used where no

161

statistically significant heterogeneity was present, whereas in the presence of statistically

significant heterogeneity defined by an I2 of 50% or above, a random effects model was

applied.

We made two main comparisons. The first main comparison aimed to assess the

effectiveness of low doses of gonadotropins versus high doses of gonadotropins for ovarian

stimulation. The second main comparison aimed to assess the effectiveness of ovarian

stimulation with gonadotropins combined with oral compounds such as letrozole and

clomiphene citrate (CC) versus gonadotropins.

Results

Characteristics of the studies included in the systematic review are presented in Table I.

162

Tabl

e I.

Cha

ract

eris

tics

of ra

ndom

ized

tria

ls o

f low

dos

ing

ovar

ian

stim

ulat

ion

in w

omen

with

poo

r ova

rian

rese

rve

Tria

ls e

valu

atin

g lo

w d

oses

ver

sus

high

dos

es o

f gon

adot

ropi

ns fo

r ova

rian

stim

ulat

ion

Tria

lP

artic

ipan

ts

Inte

rven

tions

outc

omes

Q

ualit

y fe

atur

es

1.B

astu

et a

l., 2

016

Des

ign:

thre

e ar

ms,

one

cen

ter R

CT.

Pop

ulat

ion:

w

omen

(n=

95)

fittin

g th

e B

olog

na c

riter

ia,

aged

18

–42

year

s,

BM

I of

19

–28.

9 kg

/m2 ,

no

met

abol

ic o

r en

docr

ine

diso

rder

s w

ith n

orm

al

horm

onal

pan

el a

nd u

terin

e ca

vity

. E

xclu

sion

cr

iteria

: w

omen

w

ith

a hi

stor

y of

cy

toto

xic

chem

othe

rapy

an

d/or

ra

diot

hera

py,

hist

ory

of

ovar

ian

surg

ery

such

as

oo

phor

ecto

my

or

cyst

ecto

my,

his

tory

of

dehy

droe

pian

dros

tero

ne

and/

or

test

oste

rone

su

pple

men

t us

e,

wom

en

unde

rgoi

ng n

atur

al IV

F cy

cle

Ova

rian

stim

ulat

ion:

Low

dos

es -

I(n

=31)

15

0IU

HM

G a

nd 1

50 IU

rFS

H. L

ow d

oses

-II

(n=

33) 7

5 IU

HM

G a

nd 7

5 IU

rFS

H a

nd 5

m

g/da

y le

trozo

le).

Hig

h do

ses:

(n=

31)

225

IU

HM

G

and

225

IU

rFSH

. D

own

regu

latio

n: 0

.25

mg

GnR

H a

ntag

onis

t in

all

arm

s. D

osag

e ad

just

men

t in

the

low

dos

e gr

oup:

no

t re

porte

d.

Initi

atio

n of

go

nado

tropi

ns in

the

low

dos

e gr

oup:

early

in

th

e fo

llicul

ar

phas

e.

LPS

: va

gina

l pr

oges

tero

ne g

el.

Embr

yo t

rans

fer

polic

y:

one

embr

yo w

as tr

ansf

erre

d to

pat

ient

s <3

5 ye

ars

of a

ge in

thei

r fir

st tw

o IV

F at

tem

pts;

tw

o em

bryo

s w

ere

trans

ferre

d on

ly a

fter

prev

ious

≥2

faile

d IV

F at

tem

pts.

In p

atie

nts

who

wer

e ag

ed ≥

35

year

s, t

wo

embr

yos

wer

etra

nsfe

rred

rega

rdle

ss o

f pre

viou

s IV

F at

tem

pts.

Prim

ary:

N

umbe

r of

re

triev

ed

oocy

tes,

S

econ

dary

: do

se

of

gona

dotro

pin

use,

num

ber

cycl

es

canc

eled

bef

ore

oocy

tes

retri

eval

, nu

mbe

r of

mat

ure

eggs

ret

rieve

d,

ferti

lizat

ion

rate

, nu

mbe

r of

cyc

les

reac

hing

ET,

chem

ical

, clin

ical

and

on

goin

g pr

egna

ncy

rate

s

Ran

dom

izat

ion:

(1

:1:1

ra

tio),

com

pute

r ge

nera

ted

sequ

ence

. C

once

aled

: ye

s.

Sam

ple

size

: ye

s.

Blin

dnes

s:

the

clin

icia

n &

embr

yolo

gist

wer

e bl

inde

d. I

TT:

yes.

Fu

ndin

g: N

ot re

porte

d

2.Y

ouss

ef e

t al.,

201

4D

esig

n: t

wo

arm

s, 5

cen

ters

ope

n la

bel,

non-

infe

riorit

y R

CT.

P

opul

atio

n:

wom

en

(n=

394)

ag

ed ≥

35

year

s, o

r irr

espe

ctiv

e of

age

a r

aise

d ba

sal F

SH

leve

l > 1

0 IU

/ml,

havi

ng a

low

ant

ral

follic

ular

cou

nt o

f ≤

5 fo

llicle

s or

poo

r ov

aria

n re

spon

se o

r cy

cle

canc

ella

tion

durin

g a

prev

ious

IV

F cy

cle

Exc

lusi

on c

riter

ia: p

re-e

xist

ing

med

ical

co

nditi

ons,

fem

ale

age

> 43

yea

rs,

cong

enita

l ut

erin

e an

omal

ies,

pol

ycys

tic o

vary

syn

drom

e or

ot

her c

ause

s fo

r ano

vula

tion.

Ova

rian

stim

ulat

ion:

Low

dos

e(n

=195

) 150

IU/d

ay r

FSH

. H

igh

dose

s:(n

=197

) 45

0 IU

of

HM

G.

Dow

n re

gula

tion:

Low

dos

e:0.

25

mg

of G

nRH

ant

agon

ist.

Hig

h do

ses:

mid

-lu

teal

lo

ng

GnR

H

agon

ist.

Dos

age

adju

stm

ent

in

the

low

do

se

grou

p:

no.

Initi

atio

n of

gon

adot

ropi

ns in

the

low

dos

e gr

oup:

early

in

the

folli

cula

r ph

ase.

LPS

: in

tram

uscu

lar

or

vagi

nal

prog

este

rone

. Em

bryo

tra

nsfe

r po

licy:

tw

o to

p qu

ality

em

bryo

s w

ere

trans

ferre

d on

da

y 3.

Tran

sfer

of

m

ore

than

2

embr

yos

was

al

low

ed w

hen

the

wom

en w

ere

mor

e th

an

40 y

ears

old

or h

ad p

oor e

mbr

yo q

ualit

y.

Prim

ary:

oong

oing

pre

gnan

cy r

ate

Sec

onda

rycl

inic

al

preg

nanc

y,

bioc

hem

ical

pr

egna

ncy

mul

tiple

pr

egna

ncy,

ear

ly p

regn

ancy

los

s,nu

mbe

r of

oo

cyte

s re

triev

ed,

num

ber

of m

etap

hase

II

oocy

tes,

fe

rtiliz

atio

n ra

te,

num

ber

of

embr

yos

obta

ined

, nu

mbe

r of

em

bryo

tran

sfer

s, to

tal r

FSH

/HM

G

dose

s us

ed

for

ovar

ian

stim

ulat

ion,

can

cella

tion

rate

, an

d dr

op-o

ut ra

te.

Ran

dom

izat

ion:

w

eb-b

ased

co

ncea

led

rand

omiz

atio

n.C

once

aled

: ye

s, S

ampl

e si

ze: y

es. B

lindn

ess:

no.

IT

T:

yes.

Fu

ndin

g:

stud

y w

as

supp

orte

d by

a

scho

lars

hip

from

N

UFF

IC-N

ethe

rland

s &

S

TDF-

Egyp

t (p

erso

nal f

ees)

.

Tabl

e I.

C

hara

cter

istic

s of

rand

omiz

ed tr

ials

of l

ow d

osin

g ov

aria

n st

imul

atio

n in

wom

en w

ith p

oor o

varia

n re

serv

e

Tria

ls e

valu

atin

g lo

w d

oses

ver

sus

high

dos

es o

f gon

adot

ropi

ns fo

r ova

rian

stim

ulat

ion

Tria

l P

artic

ipan

ts

Inte

rven

tions

ou

tcom

es

Qua

lity

feat

ures

1.

Bas

tu e

t al.,

201

6 D

esig

n: th

ree

arm

s, o

ne c

ente

r RC

T. P

opul

atio

n:

wom

en (

n=95

) fit

ting

the

Bol

ogna

crit

eria

, ag

ed

18– 4

2 ye

ars,

B

MI

of

19–2

8.9

kg/m

2 , no

m

etab

olic

or

endo

crin

e di

sord

ers

with

nor

mal

ho

rmon

al p

anel

and

ute

rine

cavi

ty.

Exc

lusi

on

crite

ria:

wom

en

with

a

hist

ory

of

cyto

toxi

c ch

emot

hera

py

and/

or

radi

othe

rapy

, hi

stor

y of

ov

aria

n su

rger

y su

ch

as

ooph

orec

tom

y or

cy

stec

tom

y, h

isto

ry o

f de

hydr

oepi

andr

oste

rone

an

d/or

te

stos

tero

ne

supp

lem

ent

use,

w

omen

un

derg

oing

nat

ural

IVF

cycl

e

Ova

rian

stim

ulat

ion:

Low

dos

es -

I (n

=31)

15

0IU

HM

G a

nd 1

50 IU

rFS

H. L

ow d

oses

- II

(n=

33) 7

5 IU

HM

G a

nd 7

5 IU

rFS

H a

nd 5

m

g/da

y le

trozo

le).

Hig

h do

ses:

(n=

31)

225

IU

H

MG

an

d 22

5 IU

rF

SH

. D

own

regu

latio

n: 0

.25

mg

GnR

H a

ntag

onis

t in

all

arm

s. D

osag

e ad

just

men

t in

the

low

dos

e gr

oup:

no

t re

porte

d.

Initi

atio

n of

go

nado

tropi

ns in

the

low

dos

e gr

oup:

ear

ly

in

the

folli

cula

r ph

ase.

LP

S:

vagi

nal

prog

este

rone

gel

. E

mbr

yo t

rans

fer

polic

y:

one

embr

yo w

as tr

ansf

erre

d to

pat

ient

s <3

5 ye

ars

of a

ge in

thei

r fir

st tw

o IV

F at

tem

pts;

tw

o em

bryo

s w

ere

trans

ferr

ed o

nly

afte

r pr

evio

us ≥

2 fa

iled

IVF

atte

mpt

s. In

pat

ient

s w

ho w

ere

aged

≥ 3

5 ye

ars,

tw

o em

bryo

s w

ere

trans

ferr

ed re

gard

less

of p

revi

ous

IVF

atte

mpt

s.

Prim

ary:

N

umbe

r of

re

triev

ed

oocy

tes,

S

econ

dary

: do

se

of

gona

dotro

pin

use,

num

ber

cycl

es

canc

eled

bef

ore

oocy

tes

retri

eval

, nu

mbe

r of

mat

ure

eggs

ret

rieve

d,

ferti

lizat

ion

rate

, nu

mbe

r of

cyc

les

reac

hing

ET,

che

mic

al, c

linic

al a

nd

ongo

ing

preg

nanc

y ra

tes

Ran

dom

izat

ion:

(1

:1:1

ra

tio),

c om

pute

r ge

nera

ted

sequ

ence

. C

once

aled

: ye

s.

Sam

ple

size

: ye

s.

Blin

dnes

s:

the

clin

icia

n &

em

bryo

logi

st w

ere

blin

ded.

ITT

: ye

s.

Fund

ing:

Not

repo

rted

2.

You

ssef

et a

l., 2

014

Des

ign:

tw

o ar

ms,

5 c

ente

rs o

pen

labe

l, no

n-in

ferio

rity

RC

T.

Pop

ulat

ion:

w

omen

(n

= 39

4)

aged

≥ 3

5 ye

ars,

or

irres

pect

ive

of a

ge a

rai

sed

basa

l FS

H le

vel >

10

IU/m

l, ha

ving

a lo

w a

ntra

l fo

llicu

lar

coun

t of

≤ 5

fol

licle

s or

poo

r ov

aria

n re

spon

se o

r cy

cle

canc

ella

tion

durin

g a

prev

ious

IV

F cy

cle

Exc

lusi

on c

riter

ia: p

re-e

xist

ing

med

ical

co

nditi

ons,

fem

ale

age

> 43

yea

rs,

cong

enita

l ut

erin

e an

omal

ies,

pol

ycys

tic o

vary

syn

drom

e or

ot

her c

ause

s fo

r ano

vula

tion.

Ova

rian

stim

ulat

ion:

Low

dos

e (n

=195

) 15

0 IU

/day

rFS

H.

Hig

h do

ses:

(n=

197)

450

IU

of

HM

G.

Dow

n re

gula

tion:

Low

dos

e: 0

.25

mg

of G

nRH

ant

agon

ist.

Hig

h do

ses:

mid

-lu

teal

lo

ng

GnR

H

agon

ist.

Dos

age

adju

stm

ent

in

the

low

do

se

grou

p:

no.

Initi

atio

n of

gon

adot

ropi

ns i

n th

e lo

w d

ose

grou

p: e

arly

in

the

folli

cula

r ph

ase.

LP

S:

intra

mus

cula

r or

va

gina

l pr

oges

tero

ne.

Em

bryo

tra

nsfe

r po

licy:

tw

o to

p qu

ality

em

bryo

s w

ere

trans

ferr

ed

on

day

3.

Tran

sfer

of

m

ore

than

2

embr

yos

was

al

low

ed w

hen

the

wom

en w

ere

mor

e th

an

40 y

ears

old

or h

ad p

oor e

mbr

yo q

ualit

y.

Prim

ary:

oon

goin

g pr

egna

ncy

rate

S

econ

dary

cl

inic

al

preg

nanc

y,

bioc

hem

ical

pr

egna

ncy

mul

tiple

pr

e gna

ncy,

ear

ly p

regn

ancy

los

s,

num

ber

of

oocy

tes

retri

eved

, nu

mbe

r of

met

apha

se I

I oo

cyte

s,

ferti

lizat

ion

rate

, nu

mbe

r of

em

bryo

s ob

tain

ed,

num

ber

of

embr

yo tr

ansf

ers,

tota

l rFS

H/H

MG

do

ses

used

fo

r ov

aria

n st

imul

atio

n, c

ance

llatio

n ra

te,

and

drop

-out

rate

.

Ran

dom

izat

ion:

w

eb-b

ased

co

ncea

led

rand

omiz

atio

n. C

once

aled

: ye

s, S

ampl

e si

ze: y

es. B

lindn

ess:

no.

IT

T:

yes.

Fu

ndin

g:

stud

y w

as

supp

orte

d by

a

scho

lars

hip

from

N

UFF

IC-N

ethe

rland

s &

S

TDF-

Egy

pt

(per

sona

l fee

s).

163

3.B

erkk

aogl

u &

Ozg

ur

2010

Des

ign:

thre

e ar

ms,

one

cen

ter R

CT.

Pop

ulat

ion:

w

omen

(n=

119

) ag

ed <

42 y

ears

and

an

AFC

<1

2, in

form

ed c

onse

nt.

Exc

lusi

on c

riter

ia:

basa

l FS

H >

12

IU/l

Ova

rian

stim

ulat

ion:

Low

dos

e I(

n=38

) 300

IU r

FSH

, Lo

w d

ose

II(n

= 39

) 45

0 IU

Hig

h do

ses

(n=4

2)

600

IU

rFS

H.

Dow

n re

gula

tion:

40 m

g of

leu

prol

ide

acet

ate

in

both

arm

s. D

osag

e ad

just

men

t in

the

low

do

se

grou

p:

not

repo

rted.

In

itiat

ion

of

gona

dotro

pins

in th

e lo

w d

ose

grou

p:ea

rly

in

the

follic

ular

ph

ase.

LP

S:

vagi

nal

prog

este

rone

gel

. Em

bryo

tra

nsfe

r po

licy:

embr

yo tr

ansf

ers

wer

e ro

utin

ely

perfo

rmed

on

day

2.

Prim

ary:

Clin

ical

pr

egna

ncy

rate

Sec

onda

rynu

mbe

r of

oo

cyte

s re

triev

ed,

num

ber

of m

etap

hase

II

oocy

tes,

fer

tiliz

atio

n ra

te,

num

ber

of e

mbr

yos

obta

ined

, n u

mbe

r of

em

bryo

tra

nsfe

rs,

tota

l FS

H/H

MG

do

ses

used

fo

r ov

aria

n st

imul

atio

n, c

ance

llatio

n ra

te.

Ran

dom

izat

ion:

com

pute

r ge

nera

ted

list.

Con

ceal

ed: u

ncle

ar, S

ampl

e si

ze:

no.

Blin

dnes

s:

no.

ITT:

un

clea

r. Fu

ndin

g: n

o

4.K

im e

t al.,

200

9D

esig

n: t

wo

arm

s, o

ne c

ente

r R

CT.

Pop

ulat

ion:

w

omen

(n=

90)

in g

ood

heal

th, a

ged

not s

tate

d,

prev

ious

IVF

cycl

e w

ith ≤

3 r

etrie

ved

folli

cles

on

high

do

se

of

gona

dotro

pins

, w

ritte

n in

form

ed

cons

ent,

Exc

lusi

on

crite

ria

irreg

ular

cy

cle,

ab

norm

al s

exua

l dev

elop

men

t, hi

stor

y of

fer

tility

dr

ug u

se in

pre

viou

s 3

mon

ths.

Ova

rian

stim

ulat

ion:

Low

dos

e(n

= 45

) 15

0IU

/day

rec

.FS

H f

rom

CD

7-8

. H

igh

dose

s (n

= 45

) 22

5 IU

of

rFS

H.

Dow

n re

gula

tion:

0.

25 m

g/da

y G

nRH

ant

agon

ist i

n bo

th a

rms

Dos

age

adju

stm

ent

in t

he lo

w d

ose

grou

p:

not

repo

rted.

Ini

tiatio

n of

gon

adot

ropi

ns i

n th

e lo

w d

ose

grou

p:la

te in

the

mid

-folli

cula

r ph

ase

(lead

ing

follic

le >

13.

LPS:

vag

inal

pr

oges

tero

ne g

el.

Embr

yo t

rans

fer

polic

y:

one

to fo

ur e

mbr

yos

afte

r IV

F or

ICS

I wer

e tra

nsfe

rred

into

the

ute

rus

on 3

rdda

y af

ter

oocy

te re

triev

al.

Prim

ary:

clin

ical

pr

egna

ncy,

S

econ

dary

ongo

ing

preg

nanc

y ra

te,

mul

tiple

pr

egna

ncy,

ea

rly

preg

nanc

y lo

ss ,

num

ber o

f ooc

ytes

re

triev

ed,

num

ber

of m

etap

hase

II

oocy

tes,

fer

tiliz

atio

n ra

te,

num

ber

of e

mbr

yos

obta

ined

, n u

mbe

r of

em

bryo

tra

nsfe

rs,

tota

l FS

H/H

MG

do

ses

used

fo

r ov

aria

n st

imul

atio

n, c

ance

llatio

n ra

te.

Ran

dom

izat

ion:

ra

ndom

ly

allo

cate

d by

the

use

of s

eale

d en

velo

pes

and

a co

mpu

ter-g

ener

ated

lis

t. C

once

aled

ye

s,

Sam

ple

size

: no

. B

lindn

ess:

un

clea

r. IT

T:

uncl

ear.

Fund

ing:

re

sear

ch g

rant

from

the

Asi

an in

stitu

te

for l

ife s

cien

ces.

5.K

linke

rt et

al.,

200

5D

esig

n: o

pen

labe

l, on

e ce

nter

non

-infe

riorit

y R

CT.

Pop

ulat

ion:

wom

en (

n=52

) ag

e <

46,

are

gula

r sp

onta

neou

s m

enst

rual

cyc

le o

f 25

–35

days

, th

e pr

esen

ce o

f bo

th o

varie

s an

d w

ritte

n in

form

ed c

onse

nt.

AFC

< 5

fol

licle

s E

xclu

sion

cr

iteria

: pr

e-ex

istin

g m

edic

al

cond

ition

s co

ngen

ital

uter

ine

anom

alie

s, p

olyc

ystic

ova

ry

synd

rom

e an

d an

y ot

her c

ause

s fo

r ano

vula

tion.

Ova

rian

stim

ulat

ion:

Low

dos

e(n

=26)

150

IU/d

ay r

FSH

, ad

just

ed t

o 30

0 IU

/day

in

case

E2

< 20

0 pg

/ml.

Hig

h do

ses

(n=

26)

300

IU o

f rFS

H. D

own

regu

latio

n: m

id-lu

teal

lo

ng G

nRH

ago

nist

in b

oth

grou

ps. D

osag

e ad

just

men

t in

the

low

dos

e gr

oup:

yes

in 9

w

omen

on

ly,

but

all

thes

e pa

tient

s re

mai

ned

poor

re

spon

ders

. In

itiat

ion

of

gona

dotro

pins

in th

e lo

w d

ose

grou

p:ea

rly

in t

he f

ollic

ular

pha

se.

LPS

: by

hC

G o

r pr

oges

tero

ne. E

mbr

yo tr

ansf

er p

olic

y:

The

max

imum

nu

mbe

r of

em

bryo

s re

plac

ed

was

two

in w

omen

age

d 38

yea

rs a

nd 3

in

olde

r wom

en.

Prim

ary:

num

ber

of

oocy

tes

retri

eved

, S

econ

dary

clin

ical

pr

egna

ncy

rate

and

poo

r res

pons

e.

Ran

dom

izat

ion:

com

pute

r ge

nera

ted

list.

Con

ceal

ed:

yes,

S

ampl

e si

ze:

yes.

B

lindn

ess:

un

clea

r. IT

T:

yes.

Fu

ndin

g: n

o.

3.

Ber

kkao

glu

&

Ozg

ur

2010

D

esig

n: th

ree

arm

s, o

ne c

ente

r RC

T. P

opul

atio

n:

wom

en (

n= 1

19)

aged

<42

yea

rs a

nd a

n A

FC

<12 ,

info

rmed

con

sent

. E

xclu

sion

crit

eria

: ba

sal

FSH

> 1

2 IU

/l

Ova

rian

stim

ulat

ion:

Low

dos

e I (

n=38

) 300

IU

rFS

H,

Low

dos

e II

(n=

39)

450

IU H

igh

dose

s (n

=42)

60

0 IU

rF

SH

. D

own

regu

latio

n: 4

0 m

g of

leu

prol

ide

acet

ate

in

both

arm

s. D

osag

e ad

just

men

t in

the

low

do

se

grou

p:

not

repo

rted.

In

itiat

ion

of

gona

dotro

pins

in th

e lo

w d

ose

grou

p: e

arly

in

th

e fo

llicu

lar

phas

e.

LPS

: va

gina

l pr

oges

tero

ne g

el.

Em

bryo

tra

nsfe

r po

licy:

em

bryo

tran

sfer

s w

ere

rout

inel

y pe

rform

ed

on d

ay 2

.

Prim

ary:

C

linic

al

preg

nanc

y ra

te

Sec

onda

ry

num

ber

of

oocy

tes

retri

eved

, nu

mbe

r of

met

apha

se I

I oo

cyte

s, f

ertil

izat

ion

rate

, nu

mbe

r of

em

bryo

s ob

tain

ed,

num

ber

of

embr

yo t

rans

fers

, to

tal

FSH

/HM

G

dose

s us

ed

for

ovar

ian

stim

ulat

ion,

can

cella

tion

rate

.

Ran

dom

izat

ion:

com

pute

r ge

nera

ted

list.

Con

ceal

ed: u

ncle

ar, S

ampl

e si

ze:

no.

Blin

dnes

s:

no.

ITT:

un

clea

r. Fu

ndin

g: n

o

4.

Kim

et a

l., 2

009

Des

ign:

tw

o ar

ms,

one

cen

ter

RC

T. P

opul

atio

n:

wom

en (

n= 9

0) in

goo

d he

alth

, age

d no

t sta

ted,

pr

evio

us IV

F cy

cle

with

≤ 3

ret

rieve

d fo

llicl

es o

n hi

gh

dose

of

go

nado

tropi

ns,

writ

ten

info

rmed

co

nsen

t, E

xclu

sion

cr

iteria

irr

egul

ar

cycl

e,

abno

rmal

sex

ual d

evel

opm

ent,

hist

ory

of f

ertil

ity

drug

use

in p

revi

ous

3 m

onth

s.

Ova

rian

stim

ulat

ion:

Low

dos

e (n

= 45

) 15

0 IU

/day

rec

.FS

H f

rom

CD

7-8

. H

igh

dose

s ( n

= 45

) 22

5 IU

of

rFS

H.

Dow

n re

gula

tion:

0.

25 m

g/da

y G

nRH

ant

agon

ist i

n bo

th a

rms

Dos

age

adju

stm

ent

in t

he lo

w d

ose

grou

p:

not

repo

rted.

Ini

tiatio

n of

gon

adot

ropi

ns i

n th

e lo

w d

ose

grou

p: la

te in

the

mid

-folli

cula

r ph

ase

(lead

ing

folli

cle

>13.

LP

S:

vagi

nal

prog

este

rone

gel

. E

mbr

yo t

rans

fer

polic

y:

one

to fo

ur e

mbr

yos

afte

r IV

F or

ICS

I wer

e tra

nsfe

rred

into

the

ute

rus

on 3

rd d

ay a

fter

oocy

te re

triev

al.

Prim

ary:

cl

inic

al

preg

nanc

y,

Sec

onda

ry

ongo

ing

preg

nanc

y ra

te,

mul

tiple

pr

egna

ncy,

ea

rly

preg

nanc

y lo

ss ,

num

ber o

f ooc

ytes

re

triev

ed,

num

ber

of m

etap

hase

II

oocy

tes,

fer

tiliz

atio

n ra

te,

num

ber

of e

mbr

yos

obta

ined

, nu

mbe

r of

em

bryo

tra

nsfe

rs,

tota

l FS

H/H

MG

do

ses

used

fo

r ov

aria

n st

imul

atio

n, c

ance

llatio

n ra

te.

Ran

dom

izat

ion:

ra

ndom

ly

allo

cate

d by

the

use

of s

eale

d en

velo

pes

and

a co

mpu

ter-

gene

rate

d lis

t. C

once

aled

ye

s ,

Sam

ple

size

: no

. B

lindn

ess:

un

clea

r. IT

T:

uncl

ear.

Fund

ing:

re

sear

ch g

rant

from

the

Asi

an in

stitu

te

for l

ife s

cien

ces.

5.

Klin

kert

et a

l., 2

005

Des

ign:

ope

n la

bel,

one

cent

er n

on-in

ferio

rity

RC

T. P

opul

atio

n: w

omen

(n=

52)

age

< 46

, a

regu

lar

spon

tane

ous

men

stru

al c

ycle

of

25–3

5 da

ys,

the

pres

ence

of

both

ova

ries

and

writ

ten

info

rmed

con

sent

. A

FC <

5 f

ollic

les

Exc

lusi

on

crite

ria:

pre-

exis

ting

med

ical

co

nditi

ons

cong

enita

l ut

erin

e an

omal

ies,

pol

ycys

tic o

vary

sy

ndro

me

and

any

othe

r cau

ses

for a

novu

latio

n.

Ova

rian

stim

ulat

ion:

Low

dos

e (n

=26)

150

IU

/day

rFS

H,

adju

sted

to

300

IU/d

ay i

n ca

se E

2 <

200

pg/m

l. H

igh

dose

s (n

= 26

) 30

0 IU

of r

FSH

. Dow

n re

gula

tion:

mid

-lute

al

long

GnR

H a

goni

st in

bot

h gr

oups

. Dos

age

adju

stm

ent i

n th

e lo

w d

ose

grou

p: y

es in

9

wom

en

only

, bu

t al

l th

ese

patie

nts

rem

aine

d po

or

resp

onde

rs.

Initi

atio

n of

go

nado

tropi

ns in

the

low

dos

e gr

oup:

ear

ly

in t

he f

ollic

ular

pha

se.

LPS

: by

hC

G o

r pr

oges

tero

ne. E

mbr

yo tr

ansf

er p

olic

y:

The

max

imum

nu

mbe

r of

em

bryo

s re

plac

ed

was

two

in w

omen

age

d 38

yea

rs a

nd 3

in

olde

r wom

en.

Prim

ary:

nu

mbe

r of

oo

cyte

s re

triev

ed,

Sec

onda

ry

clin

ical

pr

egna

ncy

rate

and

poo

r res

pons

e.

Ran

dom

izat

ion:

com

pute

r ge

nera

ted

list.

Con

ceal

ed:

yes,

S

ampl

e si

ze:

yes .

B

lindn

ess:

un

clea

r. IT

T:

yes.

Fu

ndin

g: n

o.

164

6.K

olib

iana

kis

et

al.,

2015

Des

ign:

tw

o ar

ms,

one

cen

ter

open

lab

el,

non-

infe

riorit

y R

CT.

Pop

ulat

ion:

wom

en (

n=79

) ag

ed

<45

, with

a re

gula

r spo

ntan

eous

men

stru

al c

ycle

be

twee

n 24

–35

days

, BM

I bet

wee

n 18

–32

kg/m

2 an

d ba

sal

FSH

≤20

IU

/l an

d a

prev

ious

poo

r re

spon

se

to

ovar

ian

stim

ulat

ion,

de

fined

as

re

triev

al o

f ≤4

oocy

tes

in a

pre

viou

s IV

F cy

cle

on

450

IU/d

gon

adot

ropi

n E

xclu

sion

crit

eria

: wom

en

with

PG

S in

dica

tion.

Ova

rian

stim

ulat

ion:

Low

dos

e(n

=40)

150

m

g co

rifol

litro

pin

alfa

for 7

day

s fo

llow

ed b

y 45

0 IU

rFS

H.

Hig

h do

ses

(n=

39)

450

IU

rFS

H. D

own

regu

latio

n: a

dai

ly s

.c d

ose

of

0.25

mg

of G

nRH

ant

agon

ist i

n bo

th a

rms.

D

osag

e ad

just

men

t in

the

low

dos

e gr

oup:

no

t re

porte

d In

itiat

ion

of g

onad

otro

pins

in

the

low

dos

e gr

oup:

ear

ly i

n th

e fo

llicul

ar

phas

e. L

PS:

vag

inal

pro

gest

eron

e. E

mbr

yo

trans

fer

polic

y:

Up

to t

hree

em

bryo

s, i

n w

omen

≤40

yea

rs o

f ag

e an

d up

to

four

em

bryo

s, in

wom

en .

40 y

ears

of a

ge w

ere

trans

ferre

d on

Day

2 o

r D

ay 3

of

in v

itro

cultu

re

Prim

ary:

num

ber

of

cum

ulus

oo

cyte

co

mpl

exes

re

triev

ed.

Sec

onda

rydu

ratio

n of

stim

ulat

ion,

th

e nu

mbe

r of

M

II oo

cyte

s,

the

num

ber

of

(2pn

) zy

gote

s,

mat

urat

ion

rate

, fe

rtiliz

atio

n ra

te,

the

qual

ity o

f em

bryo

s on

Day

2 th

e nu

mbe

r of e

mbr

yos

trans

ferre

d, th

e pr

opor

tion

of w

omen

with

em

bryo

tra

nsfe

r, cl

inic

al

preg

nanc

y,

mis

carri

age

rate

.

Ran

dom

izat

ion:

co

mpu

ter-g

ener

ated

ra

ndom

izat

ion

list,

Con

ceal

ed:

yes,

S

ampl

e si

ze: y

es. B

lindn

ess:

unc

lear

. IT

T: n

o. F

undi

ng: n

o

Tabl

e I.

(Con

t.)Tr

ials

eva

luat

ing

oral

com

poun

ds w

ith g

onad

otro

pins

ver

sus

gona

dotro

pins

for

ova

rian

stim

ulat

ion

Rev

elli

et a

l., 0

14D

esig

n: t

wo

arm

s, o

ne c

ente

r R

CT.

Pop

ulat

ion:

wom

en (

n=69

5) a

ged

<43

and

aba

sal

FSH

be

twee

n 10

and

20

IU/l

and

estra

diol

(E2)

ser

um

leve

l <80

pg/

ml,

an A

MH

bet

wee

n 0.

14 a

nd 1

.0

ng/m

l and

an

AFC

fro

m 4

-10.

Exc

lusi

on c

riter

ia:

FSH

>20

IU

/l, u

ndet

ecta

ble

AM

H le

vels

, A

FC<3

an

d ag

ed >

43

Ova

rian

stim

ulat

ion:

go

nado

tropi

ns/o

ral

com

poun

ds

(n=3

55)

Clo

mip

hene

ci

trate

10

0 m

g (c

d 2-

5) a

nd 1

50 I

U/d

ay (

cd 5

). H

igh

dose

s (n

= 34

0) 3

00 I

U/d

ay H

MG

(cd

3)

, af

ter

one

wee

k in

crea

sed

to 4

50 I

U.

Dow

nreg

ulat

ion:

go

nado

tropi

ns/

oral

co

mpo

unds

: 0.

25

mg

GnR

H

anta

goni

st

Hig

h do

ses:

mid

-lute

al lo

ng G

nRH

ago

nist

. D

osag

e ad

just

men

t in

the

gon

adot

ropi

ns /

or

al c

ompo

unds

: no

t re

porte

d. I

nitia

tion

of

gona

dotro

pins

in

th

e go

nado

tropi

ns/o

ral

com

poun

ds:

mid

-fo

llicul

ar

phas

e.

LPS:

va

gina

l pr

oges

tero

ne g

el.

Embr

yo t

rans

fer

polic

y:

Afte

r 2

day s

of

in

vi

tro

cultu

re,

embr

yos

wer

e tra

nsfe

rred

in u

tero

usi

ng a

so

ft C

ook

cath

eter

, no

m

ore

than

tw

o em

bryo

s w

ere

trans

ferre

d in

ute

ro;

in r

are

case

s, s

pare

em

bryo

s w

ere

kept

in c

ultu

re

to b

e fro

zen

on d

ay 5

.

Prim

ary:

Num

ber

of

retri

eved

oo

cyte

s,

Sec

onda

ry:

tota

lly

adm

inis

tere

d, G

n do

se,

leng

th o

f th

e ov

aria

n st

imul

atio

n, fe

rtiliz

atio

n ra

te,

clin

ical

pr

egna

ncy

rate

, im

plan

tatio

n ra

te,

abor

tion

rate

, on

goin

g pr

egna

ncy

rate

.

Ran

dom

izat

ion:

co

mpu

teriz

ed

algo

rhyt

hm

with

out

any

rest

rictio

n.C

once

aled

: ye

s,

Sam

ple

size

: ye

s.

Blin

dnes

s: n

o. I

TT:

no.

Fund

ing:

not

re

porte

d.

6.

Kol

ibia

naki

s et

al

., 20

15

Des

ign:

tw

o ar

ms,

one

cen

ter

open

lab

el,

non-

infe

riorit

y R

CT.

Pop

ulat

ion:

wom

en (

n=79

) ag

ed

< 45

, w

ith

a re

gula

r sp

onta

neou

s m

enst

rual

cy

cle

betw

een

24–3

5 da

ys, B

MI b

etw

een

18–3

2 kg

/m2

and

basa

l FS

H ≤

20 I

U/l

and

a pr

evio

us

poor

res

pons

e to

ova

rian

stim

ulat

ion,

def

ined

as

retri

eval

of ≤

4 oo

cyte

s in

a p

revi

ous

IVF

cycl

e on

45

0 IU

/d g

onad

otro

pin

Exc

lusi

on c

riter

ia: w

omen

w

ith P

GS

indi

catio

n.

Ova

rian

stim

ulat

ion:

Low

dos

e (n

=40)

150

m

g co

rifol

litro

pin

alfa

for 7

day

s fo

llow

ed b

y 45

0 IU

rFS

H.

Hig

h do

ses

(n=

39)

450

IU

rFS

H. D

own

regu

latio

n: a

dai

ly s

.c d

ose

of

0.25

mg

of G

nRH

ant

agon

ist i

n bo

th a

rms.

D

osag

e ad

just

men

t in

the

low

dos

e gr

oup:

no

t re

porte

d In

itiat

ion

of g

onad

otro

pins

in

the

low

dos

e gr

oup:

ear

ly i

n th

e fo

llicu

lar

phas

e. L

PS

: vag

inal

pro

gest

eron

e. E

mbr

yo

trans

fer

polic

y:

Up

to t

hree

em

bryo

s, i

n w

omen

≤40

yea

rs o

f ag

e an

d up

to

four

em

bryo

s, in

wom

en .

40 y

ears

of

age

wer

e tra

nsfe

rred

on

Day

2 o

r D

ay 3

of

in v

itro

cultu

re

Prim

ary:

num

ber o

f cum

ulus

ooc

yte

com

plex

es

retri

eved

. S

econ

dary

du

ratio

n of

stim

ulat

ion,

the

num

ber

of M

II oo

cyte

s, th

e nu

mbe

r of (

2pn)

zy

gote

s,

mat

urat

ion

rate

, fe

rtiliz

atio

n ra

te,

the

qual

ity

of

embr

yos

on D

ay 2

the

num

ber

of

embr

yos

trans

ferre

d, th

e pr

opor

tion

of

wom

en

with

em

bryo

tra

nsfe

r, cl

inic

al

preg

nanc

y,

mis

carri

age

rate

.

Ran

dom

izat

ion:

co

mpu

ter-

gene

rate

d ra

ndom

izat

ion

list,

Con

ceal

ed:

yes,

S

ampl

e si

ze: y

es. B

lindn

ess:

unc

lear

. IT

T: n

o. F

undi

ng: n

o

165

Kar

imza

deh

et a

l., 2

011

Des

ign:

tw

o ar

ms,

one

cen

ter

RC

T.P

opul

atio

n:W

omen

(n=

159)

age

d≥

38 y

ears

and

pre

viou

s fa

iled

IVF

cycl

es w

ith ≤

3 o

ocyt

es r

etrie

ved.

Exc

lusi

on

crite

ria:

endo

crin

e or

m

etab

olic

di

sord

ers,

ova

rian

surg

ery,

end

omet

riosi

s an

d se

vere

mal

e fa

ctor

Ova

rian

stim

ulat

ion:

go

nado

tropi

ns/o

ral

com

poun

ds(n

= 79

) Clo

mip

hene

citr

ate

100

mg/

day

(cd

3-7)

and

225

- 300

IU

/day

of

HM

G /

FSH

(cd

5)

Hig

h do

ses

(n=8

0) 2

25-

300

IU/d

ay.

Dow

nreg

ulat

ion:

gona

dotro

pins

/ora

l co

mpo

unds

:G

nRH

an

tago

nist

. H

igh

dose

s: m

icro

-flar

e G

nRH

ag

onis

t. D

osag

e ad

just

men

t in

th

ego

nado

tropi

ns/o

ral

com

poun

ds:

repo

rted.

In

itiat

ion

of

gona

dotro

pins

in

th

ego

nado

tropi

ns/o

ral

com

poun

ds:

mid

-fo

llicul

ar p

hase

. LPS

: vag

inal

pro

gest

eron

e.Em

bryo

tra

nsfe

r po

licy:

B

ased

on

th

e nu

mbe

r an

d qu

ality

of

avai

labl

e em

bryo

s an

d pa

tient

’s a

ge, o

ne to

five

em

bryo

s w

ere

trans

ferre

d on

the

day

2 o

r 3

afte

r oo

cyte

re

triev

al u

nder

ultr

asou

nd g

uida

nce

with

a

CC

D e

mbr

yo tr

ansf

er c

athe

ter.

Prim

ary:

Clin

ical

pre

gnan

cy r

ate,

S

econ

dary

dose

s of

go

nado

tropi

ns,

the

dura

tion

of

stim

ulat

ion,

th

e nu

mbe

r of

re

triev

ed

oocy

tes,

ob

tain

ed

embr

yos,

en

dom

etria

l th

ickn

ess

and

impl

anta

tion

rate

.

Ran

dom

izat

ion:

com

pute

r ge

nera

ted

rand

om

num

bers

.C

once

aled

: un

clea

r, S

ampl

e si

ze:

no.

Blin

dnes

s:

uncl

ear.

ITT:

un

clea

r. Fu

ndin

g:

not

repo

rted

Moh

sen

et a

l., 2

013

aD

esig

n: T

wo

arm

s, o

ne c

ente

r R

CT.

Pop

ulat

ion:

wom

en (n

=70)

aged

35-

42 y

ears

with

a h

isto

ry o

f po

or o

varia

n re

spon

se i

n pr

evio

us I

VF

cycl

es.

Exc

lusi

on

crite

ria:

endo

met

riosi

s,

pelv

ic

or

ovar

ian

surg

ery,

en

docr

ine

or

met

abol

ic

diso

rder

s an

d se

vere

mal

e fa

ctor

.

Ova

rian

stim

ulat

ion:

go

nado

tropi

ns/o

ral

com

poun

ds(n

=35)

: Clo

mip

hene

citr

ate

100

mg/

day

(cd

2–6)

and

HM

G 2

25 I

U/d

ay (

cd

7).

Hig

h do

ses

(n=3

5):

HM

G 3

00 I

U/d

ay.

Dow

nreg

ulat

ion:

go

nado

tropi

ns/o

ral

com

poun

ds:

0.25

m

g G

nRH

an

tago

nist

H

igh

dose

s do

sem

id-lu

teal

lo

ng

GnR

H

agon

ist

Dos

age

adju

stm

ent

in

the

gona

dotro

pins

/ora

l co

mpo

unds

: no

t re

porte

d. I

nitia

tion

of g

onad

otro

pins

in

the

gona

dotro

pins

/ora

l co

mpo

unds

:la

te i

n th

e m

id- fo

llicul

ar

phas

e.

LPS

: va

gina

l pr

oges

tero

ne.E

mbr

yo tr

ansf

er p

olic

y: u

p to

th

ree

embr

yos

wer

e tra

nsfe

rred

on d

ay 3

af

ter o

ocyt

e re

triev

al

Prim

ary:

Clin

ical

pr

egna

ncy

outc

ome

Sec

onda

ry:

tot

al d

ose

of

FS

H a

dmin

iste

red,

the

num

ber

of

mat

ure

follic

les,

cy

cle

canc

ella

tion,

nu

mbe

r of

oo

cyte

s re

triev

ed,

endo

met

rial

thic

knes

s an

d tra

nsfe

rabl

e em

bryo

s

Ran

dom

izat

ion:

com

pute

r ge

nera

ted

rand

om

num

bers

.C

once

aled

: ye

s,

Sam

ple

size

: no

. Bl

indn

ess:

no.

ITT

: un

clea

r. Fu

ndin

g: n

ot

Moh

sen

et a

l., 2

013

bD

esig

n: t

wo

arm

s, o

ne c

ente

r R

CT.

Pop

ulat

ion:

wom

en (

n=60

) ag

e no

t sta

ted,

a B

MI <

30 a

nd a

re

gula

r cy

cle

and

apr

evio

us f

aile

d IV

F du

e to

po

or o

varia

n re

spon

se to

Hig

h do

ses

stim

ulat

ion.

E

xclu

sion

cr

iteria

: en

dom

etrio

sis,

pe

lvic

or

ov

aria

n su

rger

y,

endo

crin

e or

m

etab

olic

di

sord

ers

and

seve

re m

ale

fact

or.

Ova

rian

stim

ulat

ion:

go

nado

tropi

ns/o

ral

com

poun

ds(n

=30)

let

rozo

le 2

.5m

g da

ily

(cd

2-6)

and

HM

G 1

50 IU

/day

. Hig

h do

ses

(n=3

0) H

MG

300

IU

/day

. D

ownr

egul

atio

n:

gona

dotro

pins

/ or

al c

ompo

unds

: 0.

25 m

g G

nRH

ant

agon

ist.

Hig

h do

ses:

mic

ro-fl

are

GnR

H a

goni

st.

Dos

age

adju

stm

ent

in t

hego

nado

tropi

ns/o

ral

com

poun

dsgr

oup:

not

re

porte

d. I

nitia

tion

of g

onad

otro

pins

in

the

gona

dotro

pins

/ora

l co

mpo

unds

:m

id-

follic

ular

pha

se. L

PS: v

agin

al p

roge

ster

one.

Embr

yo t

rans

fer

polic

y: d

ay 2

or

day

3 em

bryo

tra

nsfe

r (E

T) w

as p

erfo

rmed

in a

ll ca

ses

unde

r ultr

asou

nd g

uida

nce.

Prim

ary:

: C

linic

al p

regn

ancy

rat

e,

Sec

onda

ry

tota

l do

se

of

FSH

ad

min

iste

red,

th

e nu

mbe

r of

m

atur

e fo

llicle

s, c

ycle

can

cella

tion,

nu

mbe

r of

oo

cyte

s re

triev

ed,

endo

met

rial

thic

knes

s an

d tra

nsfe

rabl

e em

bryo

s

Ran

dom

izat

ion:

com

pute

r ge

nera

ted

rand

om

num

bers

.C

once

aled

: ye

s,

Sam

ple

size

: no

. Bl

indn

ess:

no.

ITT

: un

clea

r. Fu

ndin

g: n

ot

Tabl

e I.

(Con

t.)

Tria

ls e

valu

atin

g or

al c

ompo

unds

with

gon

adot

ropi

ns v

ersu

s go

nado

tropi

ns f

or o

varia

n st

imul

atio

n

Rev

elli

et a

l., 2

014

Des

ign:

tw

o ar

ms,

one

cen

ter

RC

T. P

opul

atio

n:

wom

en (

n=69

5) a

ged

<43

and

a ba

sal

FSH

be

twee

n 10

and

20

IU/l

and

estra

diol

(E2)

ser

um

leve

l <80

pg/

ml,

an A

MH

bet

wee

n 0.

14 a

nd 1

.0

ng/m

l and

an

AFC

from

4-1

0. E

xclu

sion

crit

eria

:

FSH

>20

IU

/l, u

ndet

ecta

ble

AM

H le

vels

, A

FC<3

an

d ag

ed >

43

Ova

rian

stim

ulat

ion:

go

nado

tropi

ns/o

ral

com

poun

ds

(n=3

55)

Clo

mip

hene

ci

trate

10

0 m

g (c

d 2-

5) a

nd 1

50 I

U/d

ay (

cd 5

). H

igh

dose

s (n

= 34

0) 3

00 I

U/d

ay H

MG

(cd

3)

, af

ter

one

wee

k in

crea

sed

to 4

50 I

U.

Dow

nreg

ulat

ion:

go

nado

tropi

ns/

oral

co

mpo

unds

: 0.

25

mg

GnR

H

anta

goni

st

Hig

h do

ses:

mid

-lute

al lo

ng G

nRH

ago

nist

. D

osag

e ad

just

men

t in

the

gon

adot

ropi

ns /

or

al c

ompo

unds

: no

t re

porte

d. I

nitia

tion

of

gona

dotro

pins

in

th

e go

nado

tropi

ns/o

ral

com

poun

ds:

mid

- fo

llicu

lar

phas

e.

LPS

: va

gina

l pr

oges

tero

ne g

el.

Em

bryo

tra

nsfe

r po

licy:

A

fter

2 da

ys

of

in

vitro

cu

lture

, em

bryo

s w

ere

trans

ferr

ed in

ute

ro u

sing

a

soft

Coo

k ca

thet

er,

no

mor

e th

an

two

embr

yos

wer

e tra

nsfe

rred

in

uter

o; i

n ra

re

case

s, s

pare

em

bryo

s w

ere

kept

in c

ultu

re

to b

e fro

zen

on d

ay 5

.

Prim

ary:

N

umbe

r of

re

triev

ed

oocy

tes,

S

econ

dary

: to

tally

ad

min

iste

red,

Gn

dose

, le

ngth

of

the

ovar

ian

stim

ulat

ion,

ferti

lizat

ion

rate

, cl

inic

al

preg

nanc

y ra

te,

impl

anta

tion

rate

, ab

ortio

n ra

te,

ongo

ing

preg

nanc

y ra

te.

Ran

dom

izat

ion:

co

mpu

teriz

ed

algo

rhyt

hm

with

out

any

rest

rictio

n.

Con

ceal

ed:

yes,

S

ampl

e si

ze:

yes.

B

lindn

ess:

no.

ITT

: no

. Fu

ndin

g: n

ot

repo

rted.

Kar

imza

deh

et a

l., 2

011

Des

ign:

tw

o ar

ms,

one

cen

ter

RC

T. P

opul

atio

n:

Wom

en (

n=15

9) a

ged ≥

38 y

ears

and

pre

viou

s fa

iled

IVF

cycl

es w

ith ≤

3 o

ocyt

es r

etrie

ved.

E

xclu

sion

cr

iteria

: en

docr

ine

or

met

abol

ic

diso

rder

s, o

varia

n su

rger

y, e

ndom

etrio

sis

and

seve

re m

ale

fact

or

Ova

rian

stim

ulat

ion:

gona

dotro

pins

/ora

l co

mpo

unds

(n=

79) C

lom

iphe

ne c

itrat

e 10

0 m

g/da

y (c

d 3-

7) a

nd 2

25-3

00 I

U/d

ay o

f H

MG

/FS

H (

cd 5

) H

igh

dose

s (n

=80)

225

-30

0 IU

/day

. D

ownr

egul

atio

n:

gona

dotro

pins

/ora

l co

mpo

unds

: G

nRH

an

tago

nist

. H

igh

dose

s: m

icro

-flar

e G

nRH

ag

onis

t. D

osag

e ad

just

men

t in

th

e go

nado

tropi

ns/o

ral

com

poun

ds:

repo

rted.

In

itiat

ion

of

gona

dotro

pins

in

th

e go

nado

tropi

ns/o

ral

com

poun

ds:

mid

-fo

llicu

lar p

hase

. LP

S: v

agin

al p

roge

ster

one.

E

mbr

yo

trans

fer

polic

y:

Bas

ed

on

the

num

ber

and

qual

ity o

f av

aila

ble

embr

yos

and

patie

nt’s

age

, one

to fi

ve e

mbr

yos

wer

e tra

nsfe

rred

on

the

day

2 or

3 a

fter

oocy

te

retri

eval

und

er u

ltras

ound

gui

danc

e w

ith a

C

CD

em

bryo

tran

sfer

cat

hete

r.

Prim

ary:

Clin

ical

pre

gnan

cy r

ate,

S

econ

dary

do

ses

of

gona

dotro

pins

, th

e du

ratio

n of

st

imul

atio

n,

the

num

ber

of

retri

eved

oo

cyte

s,

obta

ined

em

bryo

s,

endo

met

rial

thic

knes

s an

d im

plan

tatio

n ra

te.

Ran

dom

izat

ion:

com

pute

r ge

nera

ted

rand

om

num

bers

. C

once

aled

: un

clea

r, S

ampl

e si

ze:

no.

Blin

dnes

s:

uncl

ear.

ITT:

un

clea

r. Fu

ndin

g:

not

repo

rted

Moh

sen

et a

l., 2

013

a D

esig

n: T

wo

arm

s, o

ne c

ente

r R

CT.

Pop

ulat

ion:

w

omen

(n=7

0) a

ged

35-4

2 ye

ars

with

a h

isto

ry o

f po

or o

varia

n re

spon

se i

n pr

evio

us I

VF

cycl

es.

Exc

lusi

on

crite

ria:

endo

met

riosi

s,

pelv

ic

or

ovar

ian

surg

ery,

en

docr

ine

or

met

abol

ic

diso

rder

s an

d se

vere

mal

e fa

ctor

.

Ova

rian

stim

ulat

ion:

go

nado

tropi

ns/o

ral

com

poun

ds (n

=35)

: Clo

mip

hene

citr

ate

100

mg/

day

(cd

2–6)

and

HM

G 2

25 I

U/d

ay (

cd

7).

Hig

h do

ses

(n=3

5):

HM

G 3

00 I

U/d

ay.

Dow

nreg

ulat

ion:

go

nado

tropi

ns/o

ral

com

poun

ds:

0.25

m

g G

nRH

an

tago

nist

H

igh

dose

s do

se

mid

-lute

al

long

G

nRH

ag

onis

t D

osag

e ad

just

men

t in

th

e go

nado

tropi

ns/o

ral

com

poun

ds:

not

repo

rted.

Ini

tiatio

n of

gon

adot

ropi

ns i

n th

e

Prim

ary:

C

linic

al

preg

nanc

y ou

tcom

e S

econ

dary

: t

otal

dos

e

of F

SH

adm

inis

tere

d, t

he n

umbe

r of

m

atur

e fo

llicl

es,

cycl

e ca

ncel

latio

n,

num

ber

of

oocy

tes

retri

eved

, en

dom

etria

l th

ickn

ess

and

trans

fera

ble

embr

yos

Ran

dom

izat

ion:

com

pute

r ge

nera

ted

rand

om

num

bers

. C

once

aled

: ye

s,

Sam

ple

size

: no

. B

lindn

ess:

no.

ITT

: un

clea

r. Fu

ndin

g: n

ot

166

Lee

et a

l., 2

011

Des

ign:

tw

o ar

ms,

one

cen

ter

RC

T. P

opul

atio

n:w

omen

(n=

60)

age

<40

an A

FC o

f <5

and

a

prev

ious

poo

r IV

F re

spon

seof

< 4

ooc

ytes

. E

xclu

sion

cr

iteria

: en

docr

ine

or

met

abol

ic

diso

rder

s.

Ova

rian

stim

ulat

ion:

go

nado

tropi

ns/o

ral

com

poun

ds:

letro

zole

2.5

mg

(cd

2-6)

and

re

c.FS

H 2

25 I

U/d

ay (

cd 7

). H

igh

dose

s:H

MG

225

IU/d

ay. D

ownr

egul

atio

n: 0

.25

mg

GnR

H a

ntag

onis

t in

bot

h gr

oups

. D

osag

e ad

just

men

t n

the

gona

dotro

pins

/ or

al

com

poun

ds:

not

repo

rted.

In

itiat

ion

of

gona

dotro

pins

in

th

e go

nado

tropi

ns/o

ral

com

poun

ds:

in

the

mid

- follic

ular

ph

ase.

LP

S:

not

repo

rted.

Em

bryo

tra

nsfe

r po

licy:

A

m

axim

um

of

two

norm

ally

cl

eavi

ng

embr

yos

wer

e tra

nsfe

rred

to t

he u

terin

eca

vity

2 d

ays

afte

r the

retri

eval

.

Prim

ary:

num

ber

of

retri

eved

oo

cyte

s.

Sec

onda

ryon

goin

g pr

egna

ncy

rate

, liv

e bi

rth

rate

, se

rum

an

d fo

llicu

lar

fluid

ho

rmon

es

to

tally

ad

min

iste

red,

G

n do

se,

leng

th

of

the

ovar

ian

stim

ulat

ion,

Ran

dom

izat

ion:

com

pute

r ge

nera

ted

rand

om

num

bers

.C

once

aled

: ye

s,

Sam

ple

size

: yes

. Blin

dnes

s: u

ncle

ar.

ITT:

unc

lear

. Fun

ding

: yes

Foud

a &

Say

ed 2

011.

D

esig

n: t

wo

arm

s, o

ne c

ente

r R

CT.

Pop

ulat

ion:

wom

en (

n=13

6) a

ge <

40

who

res

pond

ed p

oorly

to

G

nRH

ag

onis

t lo

ng

prot

ocol

in

th

eir

first

IVF

cycl

e.E

xclu

sion

crit

eria

: en

docr

ine

or

met

abol

ic d

isor

ders

.

Ova

rian

stim

ulat

ion:

gona

dotro

pins

/ora

l co

mpo

unds

: 2.

5 m

g/da

y an

d FS

H

300

IU/d

ay (c

d 3)

. Hig

h do

ses:

letro

zole

5.0

mg

(cd

1-5)

2.5

mg/

day

(5-8

) an

d rF

SH

300

IU

/day

(c

d 5)

D

ownr

egul

atio

n:

0.25

m

g G

nRH

ant

agon

ist

in b

oth

grou

ps.

Dos

age

adju

stm

ent

in

the

gona

dotro

pins

/ora

l co

mpo

unds

: no

t re

porte

d.

Initi

atio

n of

go

nado

tropi

ns

in

the

gona

dotro

pins

/ora

l co

mpo

unds

:m

id- fo

llicul

ar

phas

e.

LPS

: va

gina

l pr

oges

tero

ne.

Embr

yo

trans

fer

polic

y:

Up

to

thre

e em

bryo

s w

ere

trans

ferre

d pe

r pat

ient

, 3 d

ays

afte

r ooc

ytes

re

triev

al u

nder

ultr

asou

nd g

uida

nce.

Prim

ary:

Clin

ical

pre

gnan

cy r

ate,

S

econ

dary

:nu

mbe

r of

re

triev

ed

oocy

tes,

ong

oing

pre

gnan

cy ra

te.

Ran

dom

izat

ion:

com

pute

r ge

nera

ted

rand

om

num

bers

.C

once

aled

: ye

s,

Sam

ple

size

: ye

s. B

lindn

ess:

sin

gle

blin

d. IT

T: y

es. F

undi

ng: n

o

Gos

wam

i et a

l., 2

004

Des

ign:

tw

o ar

ms,

si

ngle

ce

nter

R

CT.

P

opul

atio

n: w

omen

(n=

38)

≥ 35

yea

rs o

f ag

e,

had

faile

d on

e to

thre

e IV

F at

tem

pts

due

to p

oor

ovar

ian

resp

onse

to

H

igh

dose

s lo

ng

GnR

H

agon

ist

prot

ocol

. E

xclu

sion

cr

iteria

: se

vere

en

dom

etrio

sis,

his

tory

of p

revi

ous

pelv

ic s

urge

ry,

or b

asel

ine

FSH

≥12

mIU

/ml.

Ova

rian

stim

ulat

ion:

go

nado

tropi

ns/o

ral

com

poun

ds:

letro

zole

2.5

mg

daily

(cd

3–7

) an

d rF

SH

75

IU/d

ay (

cd 3

and

8).

Hig

h do

ses:

re

c.FS

H

(300

–450

IU

/day

). D

ownr

egul

atio

n: g

onad

otro

pins

/or

al c

ompo

unds

:no

dow

nreg

ulat

ion.

H

igh

dose

s:lo

n g

GnR

H

agon

ist.

D

osag

e ad

just

men

t in

th

e go

nado

tropi

ns/

oral

co

mpo

unds

: no

. In

itiat

ion

of g

onad

otro

pins

in

th

ego

nado

tropi

ns/o

ral

com

poun

ds:

in

the

mid

- follic

ular

ph

ase.

LP

S:

vagi

nal

prog

este

rone

. Em

bryo

tra

nsfe

r po

licy:

Em

bryo

tra

nsfe

r w

as p

erfo

rmed

40–

42 h

fo

llow

ing

inse

min

atio

n at

4–6

cel

l cle

avag

e st

ages

Prim

ary:

clin

ical

pr

egna

ncy

outc

ome,

S

econ

dary

tot

al d

ose

of

FS

H a

dmin

iste

red,

the

num

ber

of m

atur

e fo

llicle

s, t

he l

evel

s of

te

rmin

al E

2,

num

ber

of

oocy

tes

retri

eved

, en

dom

etria

l th

ickn

ess

and

trans

fera

ble

embr

yos

Ran

dom

izat

ion:

S

eque

ntia

lly

num

bere

d se

aled

en

velo

pes

wer

e pr

epar

ed a

nd p

rovi

ded

by t

he s

tudy

co

ordi

nato

r, ac

cord

ing

to

rand

om-

num

ber

tabl

es.

Con

ceal

ed:

yes,

S

ampl

e si

ze:

no.

Blin

dnes

s:

sing

le

blin

ded.

IT

T:

no.

Fund

ing:

no

t re

porte

d

Hua

ng e

t al.,

201

5 D

esig

n: n

on-in

ferio

rity

RC

T. P

opul

atio

nW

omen

(n

=105

) ag

ed

and

met

th

e B

olog

na

crite

ria.

Exc

lusi

on c

riter

ia:

hist

ory

of m

ore

than

one

IVF

failu

re

seve

re a

deno

myo

sis,

abn

orm

al u

terin

e ca

vity

, su

ch a

s in

traut

erin

e ad

hesi

ons;

PC

OS

wom

en;

hist

ory

of a

llerg

ic t

o ov

ulat

ion

indu

ctio

n

Ova

rian

stim

ulat

ion:

go

nado

tropi

ns/o

ral

com

poun

ds:

letro

zole

(c

d 3

to

7)

and

rec.

FSH

(<

150

IU/d

) (c

d 4,

6

and

8 on

war

ds).

Hig

h do

ses:

300

IU

/d r

ec.F

SH

(c

d 1-

5)

adju

sted

fro

m

cd

6 on

war

d.

Dow

nreg

ulat

ion:

gona

dotro

pins

/ or

al

Prim

ary:

clin

ical

an

d on

goin

g pr

egna

ncy

rate

s,

Sec

onda

ry

impl

anta

tion

rate

, liv

e bi

rth r

ate.

M

isca

rriag

e ra

te,

tota

l do

se

of

FSH

adm

inis

trate

d th

e nu

mbe

r of

m

atur

e fo

llicle

s, c

ycle

can

cella

tion,

Ran

dom

izat

ion:

com

pute

r ge

nera

ted

list.

Con

ceal

ed: u

ncle

ar, S

ampl

e si

ze:

yes.

B

lindn

ess:

no

. IT

T:

uncl

ear.

Fund

ing:

by

hosp

ital

Moh

sen

et a

l., 2

013

a D

esig

n: T

wo

arm

s, o

ne c

ente

r R

CT.

Pop

ulat

ion:

w

omen

(n=7

0) a

ged

35-4

2 ye

ars

with

a h

isto

ry o

f po

or o

varia

n re

spon

se i

n pr

evio

us I

VF

cycl

es.

Exc

lusi

on

crite

ria:

endo

met

riosi

s,

pelv

ic

or

ovar

ian

surg

ery,

en

docr

ine

or

met

abol

ic

diso

rder

s an

d se

vere

mal

e fa

ctor

.

Ova

rian

stim

ulat

ion:

go

nado

tropi

ns/o

ral

com

poun

ds (n

=35)

: Clo

mip

hene

citr

ate

100

mg/

day

(cd

2–6)

and

HM

G 2

25 I

U/d

ay (

cd

7).

Hig

h do

ses

(n=3

5):

HM

G 3

00 I

U/d

ay.

Dow

nreg

ulat

ion:

go

nado

tropi

ns/o

ral

com

poun

ds:

0.25

m

g G

nRH

an

tago

nist

H

igh

dose

s do

se

mid

-lute

al

long

G

nRH

ag

onis

t D

osag

e ad

just

men

t in

th

e go

nado

tropi

ns/o

ral

com

poun

ds:

not

repo

rted.

Ini

tiatio

n of

gon

adot

ropi

ns i

n th

e go

nado

tropi

ns/o

ral

com

poun

ds:

late

in

the

mid

- folli

cula

r ph

ase.

LP

S:

vagi

nal

prog

este

rone

. Em

bryo

tran

sfer

pol

icy:

up

to

thre

e em

bryo

s w

ere

trans

ferr

ed o

n da

y 3

afte

r ooc

yte

retri

eval

Prim

ary:

C

linic

al

preg

nanc

y ou

tcom

e S

econ

dary

: t

otal

dos

e

of F

SH

adm

inis

tere

d, t

he n

umbe

r of

m

atur

e fo

llicl

es,

cycl

e ca

ncel

latio

n,

num

ber

of

oocy

tes

retri

eved

, en

dom

etria

l th

ickn

ess

and

trans

fera

ble

embr

yos

Ran

dom

izat

ion:

com

pute

r ge

nera

ted

rand

om

num

bers

. C

once

aled

: ye

s,

Sam

ple

size

: no

. B

lindn

ess:

no.

ITT

: un

clea

r. Fu

ndin

g: n

ot

Moh

sen

et a

l., 2

013

b D

esig

n: t

wo

arm

s, o

ne c

ente

r R

CT.

Pop

ulat

ion:

w

omen

(n=

60)

age

not s

tate

d, a

BM

I <30

and

a

regu

lar

cycl

e an

d a

prev

ious

fai

led

IVF

due

to

poor

ova

rian

resp

onse

to H

igh

dose

s st

imul

atio

n.

Exc

lusi

on

crite

ria:

endo

met

riosi

s,

pelv

ic

or

ovar

ian

surg

ery,

en

docr

ine

or

met

abol

ic

diso

rder

s an

d se

vere

mal

e fa

ctor

.

Ova

rian

stim

ulat

ion:

go

nado

tropi

ns/o

ral

com

poun

ds

(n=3

0)

letro

zole

2.

5mg

daily

(c

d 2-

6) a

nd H

MG

150

IU/d

ay. H

igh

dose

s (n

=30)

HM

G 3

00 I

U/d

ay.

Dow

nreg

ulat

ion:

go

nado

tropi

ns/

oral

com

poun

ds:

0.25

mg

GnR

H a

ntag

onis

t. H

igh

dose

s: m

icro

-flar

e G

nRH

ago

nist

. D

osag

e ad

just

men

t in

the

go

nado

tropi

ns/o

ral

com

poun

ds g

roup

: no

t re

porte

d. I

nitia

tion

of g

onad

otro

pins

in

the

gona

dotro

pins

/ora

l co

mpo

unds

: m

id-

folli

cula

r pha

se. L

PS

: vag

inal

pro

gest

eron

e.

Em

bryo

tra

nsfe

r po

licy:

day

2 o

r da

y 3

embr

yo t

rans

fer

(ET)

was

per

form

ed in

all

case

s un

der u

ltras

ound

gui

danc

e.

Prim

ary:

: C

linic

al p

regn

ancy

rat

e,

Sec

onda

ry

tota

l do

se

of

FSH

ad

min

iste

red,

th

e nu

mbe

r of

m

atur

e fo

llicl

es, c

ycle

can

cella

tion,

nu

mbe

r of

oo

cyte

s re

triev

ed,

endo

met

rial

thic

knes

s an

d tra

nsfe

rabl

e em

bryo

s

Ran

dom

izat

ion:

com

pute

r ge

nera

ted

rand

om

num

bers

. C

once

aled

: ye

s,

Sam

ple

size

: no

. B

lindn

ess:

no.

ITT

: un

clea

r. Fu

ndin

g: n

ot

Lee

et a

l., 2

011

D

esig

n: t

wo

arm

s, o

ne c

ente

r R

CT.

Pop

ulat

ion:

w

omen

(n=

60)

age

<40

an A

FC o

f <5

and

a

prev

ious

poo

r IV

F re

spon

se o

f <

4 oo

cyte

s.

Exc

lusi

on

crite

ria:

endo

crin

e or

m

etab

olic

di

sord

ers.

Ova

rian

stim

ulat

ion:

go

nado

tropi

ns/o

ral

com

poun

ds:

letro

zole

2.5

mg

(cd

2-6)

and

re

c.FS

H 2

25 I

U/d

ay (

cd 7

). H

igh

dose

s:

HM

G 2

25 IU

/day

. Dow

nreg

ulat

ion:

0.2

5 m

g G

nRH

ant

agon

ist

in b

oth

grou

ps.

Dos

age

adju

stm

ent

n th

e go

nado

tropi

ns/

oral

co

mpo

unds

: no

t re

porte

d.

Initi

atio

n of

go

nado

tropi

ns

in

the

gona

dotro

pins

/ora

l co

mpo

unds

: in

th

e m

id-fo

llicu

lar

phas

e.

LPS

: no

t re

porte

d. E

mbr

yo t

rans

fer

polic

y:

A

max

imum

of

tw

o no

rmal

ly

clea

ving

em

bryo

s w

ere

trans

ferr

ed t

o th

e ut

erin

e ca

vity

2 d

ays

afte

r the

retri

eval

.

Prim

ary:

nu

mbe

r of

re

triev

ed

oocy

tes.

S

econ

dary

on

goin

g pr

egna

ncy

rate

, liv

e bi

rth

rate

, se

rum

an

d fo

llicu

lar

fluid

ho

rmon

es

to

tally

ad

min

iste

red,

G

n do

se,

leng

th

of

the

ovar

ian

stim

ulat

ion,

Ran

dom

izat

ion:

com

pute

r ge

nera

ted

rand

om

num

bers

. C

once

aled

: ye

s,

Sam

ple

size

: yes

. Blin

dnes

s: u

ncle

ar.

ITT:

unc

lear

. Fun

ding

: yes

Foud

a &

Say

ed 2

011.

D

esig

n: t

wo

arm

s, o

ne c

ente

r R

CT.

Pop

ulat

ion:

w

omen

(n=

136)

age

< 4

0 w

ho r

espo

nded

poo

rly

to

GnR

H

agon

ist

long

pr

otoc

ol

in

thei

r fir

st IV

F cy

cle.

Exc

lusi

on c

riter

ia:

endo

crin

e or

m

etab

olic

dis

orde

rs.

Ova

rian

stim

ulat

ion:

go

nado

tropi

ns/o

ral

com

poun

ds:

2.5

mg/

day

and

FSH

30

0 IU

/day

(cd

3).

Hig

h do

ses:

letro

zole

5.0

mg

(cd

1-5)

2.5

mg/

day

(5-8

) an

d rF

SH

300

IU

/day

(c

d 5)

D

ownr

egul

atio

n:

0.25

m

g G

nRH

ant

agon

ist

in b

oth

grou

ps.

Dos

age

adju

stm

ent

in

the

gona

dotro

pins

/ora

l co

mpo

unds

: no

t re

porte

d.

Initi

atio

n of

go

nado

tropi

ns

in

the

gona

dotro

pins

/ora

l co

mpo

unds

: m

id-fo

llicu

lar

phas

e.

LPS

: va

gina

l pr

oges

tero

ne.

Em

bryo

tra

nsfe

r po

licy:

U

p to

th

ree

embr

yos

wer

e tra

nsfe

rred

per

pat

ient

, 3 d

ays

afte

r ooc

ytes

re

triev

al u

nder

ultr

asou

nd g

uida

nce.

Prim

ary:

Clin

ical

pre

gnan

cy r

ate,

S

econ

dary

: nu

mbe

r of

re

triev

ed

oocy

tes,

ong

oing

pre

gnan

cy ra

te.

Ran

dom

izat

ion:

com

pute

r ge

nera

ted

rand

om

num

bers

. C

once

aled

: ye

s,

Sam

ple

size

: ye

s. B

lindn

ess:

sin

gle

blin

d. IT

T: y

es. F

undi

ng: n

o

167

med

icin

es;

atte

ndin

g ot

her

clin

ical

tria

ls i

n th

e sa

me

perio

d.co

mpo

unds

: G

nRH

ant

agon

ist

in c

ase

of

prem

atur

e LH

ris

e H

igh

dose

s: G

nRH

-alo

ng ‘s

top’

pro

toco

l. D

osag

e ad

just

men

t in

the

lgo

nado

tropi

ns/o

ral

com

poun

ds:

not

repo

rted.

Ini

tiatio

n of

gon

adot

ropi

ns i

n th

ego

nado

tropi

ns/o

ral

com

poun

ds:

early

fo

llicul

ar.

LPS

:

not

repo

rted.

Em

bryo

tra

nsfe

r pol

icy:

unc

lear

and

num

ber

of o

ocyt

es r

etrie

ved,

en

dom

etria

l th

ickn

ess

and

trans

fera

ble

embr

yos,

num

ber

of

good

qua

lity

embr

yos,

E2

and

LH

leve

ls o

n da

y of

HC

G.

Gos

wam

i et a

l., 2

004

Des

ign:

tw

o ar

ms,

si

ngle

ce

nter

R

CT.

P

opul

atio

n: w

omen

(n=

38) ≥

35 y

ears

of

age,

ha

d fa

iled

one

to th

ree

IVF

atte

mpt

s du

e to

poo

r ov

aria

n re

spon

se

to

Hig

h do

ses

long

G

nRH

ag

onis

t pr

otoc

ol.

Exc

lusi

on

crite

ria:

seve

re

endo

met

riosi

s, h

isto

ry o

f pre

viou

s pe

lvic

sur

gery

, or

bas

elin

e FS

H ≥

12 m

IU/m

l.

Ova

rian

stim

ulat

ion:

go

nado

tropi

ns/o

ral

com

poun

ds:

letro

zole

2.5

mg

daily

(cd

3–7

) an

d rF

SH

75

IU/d

ay (

cd 3

and

8).

Hig

h do

ses:

re

c.FS

H

(300

–450

IU

/day

). D

ownr

egul

atio

n: g

onad

otro

pins

/ or

al c

ompo

unds

: no

dow

nreg

ulat

ion.

H

igh

dose

s:

long

G

nRH

ag

onis

t.

Dos

age

adju

stm

ent

in

the

gona

dotro

pins

/ or

al

com

poun

ds:

no.

Initi

atio

n of

gon

adot

ropi

ns

in

the

gona

dotro

pins

/ora

l co

mpo

unds

: in

th

e m

id-fo

llicu

lar

phas

e.

LPS

: va

gina

l pr

oges

tero

ne.

Em

bryo

tra

nsfe

r po

licy:

E

mbr

yo t

rans

fer

was

per

form

ed 4

0–42

h

follo

win

g in

sem

inat

ion

at 4

–6 c

ell c

leav

age

stag

es

Prim

ary:

cl

inic

al

preg

nanc

y ou

tcom

e,

Sec

onda

ry t

otal

dos

e

of F

SH

adm

inis

tere

d, t

he n

umbe

r of

mat

ure

folli

cles

, th

e le

vels

of

term

inal

E

2,

num

ber

of

oocy

tes

retri

eved

, en

dom

etria

l th

ickn

ess

and

trans

fera

ble

embr

yos

Ran

dom

izat

ion:

S

eque

ntia

lly

num

bere

d se

aled

en

velo

pes

wer

e pr

epar

ed a

nd p

rovi

ded

by t

he s

tudy

co

ordi

nato

r, ac

cord

ing

to

rand

om-

num

ber

tabl

es.

Con

ceal

ed:

yes,

S

ampl

e si

ze:

no.

Blin

dnes

s:

sing

le

blin

ded.

IT

T:

no.

Fund

ing:

no

t re

porte

d

Hua

ng e

t al.,

201

5

Des

ign:

non

-infe

riorit

y R

CT.

Pop

ulat

ion

Wom

en

(n=1

05)

aged

an

d m

et

the

Bol

ogna

cr

iteria

. E

xclu

sion

crit

eria

: hi

stor

y of

mor

e th

an o

ne IV

F fa

ilure

se

vere

ade

nom

yosi

s, a

bnor

mal

ute

rine

cavi

ty,

such

as

intra

uter

ine

adhe

sion

s; P

CO

S

wom

en;

hist

ory

of a

llerg

ic t

o ov

ulat

ion

indu

ctio

n m

edic

ines

; at

tend

ing

othe

r cl

inic

al t

rials

in

the

sam

e pe

riod.

Ova

rian

stim

ulat

ion:

gona

dotro

pins

/ora

l co

mpo

unds

: le

trozo

le

(cd

3 to

7)

an

d re

c.FS

H

(<15

0 IU

/d)

(cd

4,

6 an

d 8

onw

ards

). H

igh

dose

s: 3

00 I

U/d

rec

.FS

H

(cd

1-5)

ad

just

ed

from

cd

6

onw

ard.

D

ownr

egul

atio

n:

gona

dotro

pins

/ or

al

com

poun

ds:

GnR

H a

ntag

onis

t in

cas

e of

pr

emat

ure

LH r

ise

Hig

h do

ses:

GnR

H-a

lo

ng ‘s

top’

pro

toco

l. D

osag

e ad

just

men

t in

the

l go

nado

tropi

ns/o

ral

com

poun

ds:

not

repo

rted.

Ini

tiatio

n of

gon

adot

ropi

ns i

n th

e go

nado

tropi

ns/o

ral

com

poun

ds:

early

fo

llicu

lar.

LPS

:

not

repo

rted.

E

mbr

yo

trans

fer p

olic

y: u

ncle

ar

Prim

ary:

cl

inic

al

and

ongo

ing

preg

nanc

y ra

tes,

S

econ

dary

im

plan

tatio

n ra

te,

live

birth

rat

e.

Mis

carr

iage

ra

te,

tota

l do

se

of

FSH

adm

inis

trate

d th

e nu

mbe

r of

m

atur

e fo

llicl

es, c

ycle

can

cella

tion,

an

d nu

mbe

r of

ooc

ytes

ret

rieve

d,

endo

met

rial

thic

knes

s an

d tra

nsfe

rabl

e em

bryo

s, n

umbe

r of

go

od q

ualit

y em

bryo

s, E

2 an

d LH

le

vels

on

day

of H

CG

.

Ran

dom

izat

ion:

com

pute

r ge

nera

ted

list.

Con

ceal

ed: u

ncle

ar, S

ampl

e si

ze:

yes.

B

lindn

ess:

no

. IT

T:

uncl

ear.

Fund

ing:

by

hosp

ital

168

Description of included studies

From the bibliographic searches, we retrieved 788 publications in total (Figure 1). We

screened the titles of these manuscripts and considered 36 studies to be potentially eligible

for inclusion in the review. We excluded 21 studies; 14 studies after reading the abstracts,

four studies since they were ongoing (Royan institute study 2015; Fondazione IRCCS 2011;

Bioroma 2014; Sun Yat –Sen University 2016), one RCT since it used natural cycle with zero

dose of gonadotropins (Morgia et al., 2004) and two RCTs that compared high doses of

gonadotropins versus high doses of gonadotropins (Cedrin-Durnerin et al., 2000; Lefebvre et

al., 2015).

169

Figure 1: Flow diagram for meta-analysis. Identification and selection of publications

Records identified through database searching PubMed, web of Science and

EMBASE (n=754)

Scre

enin

g

Incl

uded

E

ligib

ility

Iden

tific

atio

n Additional records identified through

Cochrane (n= 4)

Clinical trials registers (n=30)

Records after duplicates removed (n=443)

Records screened (n = 443) Records excluded (n = 407)

Full-text articles assessed for eligibility (n=36)

Full-text articles excluded (n=21)

Compared the same dose of Gn. (n=13).

Used natural cycle (n=1)

Duplicate publication (n=1)

Poor response not demonstrated (n=1)

Quasi-randomization (n=1)

Ongoing studies (n=4)

Studies included in the analysis (n = 15)

Low dose vs. high dose (n=5)

Gonadotropins with oral compounds vs. gonadotropins (n=8)

Low dose of gonadotropins vs. gonadotropins with oral compounds vs. high dose (n=1) for this reason is counted as two studies

Gonadotropins with oral compounds vs. gonadotropins (n = 9)

Letrozole (n= 6)

Clomiphene citrate (n=3)

Low dose of gonadotropins vs. high doseof gonadotropins (n=6))

170

We thus included 15 studies in the present systematic review (Bastu et al., 2016;;

Kolibianakis et al., 2015; Berkkaoglu & Ozgur 2010; Kim et al., 2009; Klinkert et al.,

2005;Youssef et al., 2014; Haung et al., 2015; Revelli et al., 2014; Karimzadeh et al., 2011;

Mohsen et al., 2013 a; Mohsen et al., 2013 b; Lee et al., 2011; Fouda & Sayed 2011;

Goswami et al., 2004). Two studies were three-armed RCTs (Bastu et al., 2016; Berkkanoglu

& Ozgur 2010). The first study compared 150 IU of gonadotropins plus letrozole versus 300

IU of gonadotropins versus 450 IU of gonadotropins (Bastu et al., 2016). We included the

data from the 300 IU and 450 IU arms in main comparison I. We included data from the 150

IU gonadotropins plus letrozole and the 450 IU arm in main comparison II. The second study

compared 300 IU versus 450 IU versus 600 IU of gonadotropins (Berkkanoglu & Ozgur

2010). We analyzed only data from the 300 IU and 600 IU arms in the low doses of

gonadotropins versus high doses of gonadotropins comparison. Two studies were not yet

published as a full text and were available only as conference proceeding abstracts (Youssef

et al., 2014; Haung et al., 2015).

Setting

The studies were conducted in the Netherlands, Italy, Canada, China, South Korea, Egypt,

Iran, Turkey, India, Greece, and France and were published between 2000 and 2016 (Table

I). The number of patients included ranged from 38 to 695 patients (median 95). All studies

were randomized controlled parallel studies.

Population

The criteria for selecting women with poor ovarian reserve varied across studies such as

poor response in a previous IVF cycle (Kolibianakis et al., 2015; Mohsen et al., 2013 a & b;

Lee et al., 2011; Fouda & Sayed 2011; Kim et al., 2009; Goswami et al., 2004), based on

results of ovarian reserve tests (Revelli et al., 2014; Berkkanoglu & Ozgur 2010;Klinkert et

al., 2005), Bologna criteria (Bastu et al., 2016; Haung et al., 2015) or a combination of these

(Youssef et al., 2014; Karimzadeh et al., 2011).

Grading of bias

Randomization methods were reported clearly in 14 studies (Bastu et al., 2016; Kolibianakis

et al., 2015; Youssef et al., 2014; Klinkert et al., 2005; Haung et al., 2015; Revelli et al.,

2014; Mohsen et al., 2013 a; Mohsen et al., 2013 b; Lee et al., 2011; Karimzadeh et al.,

2011; Fouda & Sayed 2011; Goswami et al., 2004; Berkkanoglu & Ozgur 2010; Kim et al.,

2009).

171

Ten studies were judged to be at low risk for selection bias since they used an adequate

method of allocation concealment (Bastu et al., 2016; Youssef et al., 2014; Kolibianakis et

al., 2015; Mohsen et al., 2013 a & b; Lee et al., 2011; Fouda & Sayed 2011; Goswami et al.,

2004; Revelli et al., 2014; Klinkert et al., 2005). The other studies were judged as being of

unclear risk because the information was not reported.

Power analysis was performed in eight studies. Five studies that performed sample sizes

based on the number of oocytes were judged at high risk of type II error. (Bastu et al., 2016;

Kolibianakis et al., 2015; Revelli et al., 2014; Lee et al., 2011; Klinkert et al., 2005). Two

studies calculated sample size based on pregnancy outcomes and were judged at low risk of

type II error. (Youssef et al., 2014; Fouda & Sayed 2011)

Blinding of clinicians and embryologists was reported in three studies, but blinding of women

was not possible for the type of intervention compared. (Bastu et al., 206; Fouda & Sayed et

al., 2011; Goswami et al., 2004). As we considered it unlikely that blinding affected

pregnancy outcome for the comparisons under study, we judged all studies to have low risk

of performance bias. All studies were judged as being at low risk for detection bias because

the outcomes were objective. Financial support was declared in 3 studies (Haung et al.,

2015; Youssef et al., 2014; Kim et al., 2009) (Table I).

We judged all studies to be at low risk of attrition bias because there were no, or very few,

women withdrawn from the studies, and they were balanced between the interventions. All

studies were judged at low risk of selective outcome reporting bias, because the results of

relevant outcomes like pregnancy rates, number of oocytes and ovarian stimulation

outcomes were reported.

Stimulation regimes

We found 6 studies comparing ovarian stimulation with low doses of gonadotropins versus

high doses of gonadotropins (Bastu et al., 2016; Kolibianakis et al., 2015; Youssef et al.,

2014; Berkkaoglu & Ozgur 2010; Kim et al., 2009; Klinkert et al., 2005;).

We found 9 studies using gonadotropins with co-treatment by oral compounds for ovarian

stimulation in IVF cycles compared to gonadotropins (Bastu et al., 2016; Haung et al., 2015;

Revelli et al., 2014; Karimzadeh et al., 201; Mohsen et al., 2013 a; Mohsen et al., 2013 b;

Lee et al., 2011; Fouda & Sayed 2011; Goswami et al., 2004).

To inhibit premature LH surges, GnRH antagonists were used in five studies (Bastu et al.,

2016; Kolibianakis et al., 2015; Kim et al., 2009; Lee et al., 2011; Fouda & Sayed 2011),

172

micro flare GnRH agonists were used in one study (Berkkanoglu & Ozgur 2010). Both GnRH

antagonist and mid-luteal long GnRH agonists were used in three studies (Youssef et al.,

2014; Haung et al., 2015; Revelli et al., 2014). GnRH antagonists, as well as micro-dose flare

up GnRH agonists were used in two studies (Mohsen et al., 2013 b; Karimzadeh et al.,

2011). No down regulation was used in the low doses arm of one study, while micro-dose

flare up GnRH agonist and mid-luteal GnRH agonist were used in the high doses of

gonadotropins arm respectively. (Goswami et al., 2004). Mid luteal long GnRH agonist

regimen was used in both arms in one study (Klinkert et al., 2005).

Ovarian stimulation was performed by daily injections of rec FSH in 5 studies, (Kolibianakis

et al., 2015; Berkkanoglu & Ozgur 2010; Kim et al., 2009; Klinkert et al., 2005; Goswami et

al., 2004), HP/P-FSH in one study (Fouda & Sayed 2011), HMG in 4 studies (Revelli et al.,

2014; Lee et al., 2011; Mohsen et al., 2013 a & b), whereas both FSH and HMG were

applied in 3 studies (Bastu et al., 2016; Youssef et al., 2014; Karimzadeh et al., 2011). One

study used 150 mg (≈ 200 IU of FSH) of the long acting rec FSH (Corifollitropin alfa) in the

low doses of gonadotropins arm, before the dose was increased to 450 IU / day from day 8

of stimulation (Kolibianakis et al., 2015). The onset of administration of gonadotropins in the

low doses arm was early (cycle days 2-3) in six studies, and initiated late (cycle days 5-7) for

the other 9 studies (Revelli et al., 2014; Haung et al., 2015; Kim et al., 2009; Karimzadeh et

al., 2011; Mohsen et al., 2011 a & b; Lee et al., 2011; Fouda & Sayed 2011; Goswami et al.,

2004).

In the low doses regimens, the dose of gonadotropins ranged from 150 IU of gonadotropins

(Klinkert et al., 2005; Kim et al., 2009; Youssef et al., 2014; Kolibianakis et al., 2015) to

300IU (Berkkanoglu & Ozgur 2010; Bastu et al., 2016), whereas in the high doses of

gonadotropins regimens it ranged from 225 IU of gonadotropins (Kim et al., 2009) to 600 IU

(Berkkanoglu & Ozgur 2010).

Co-treatment with oral compounds was reported in nine studies. Eight studies used oral

compounds as a pre-treatment before the initiation of gonadotropins and one study used it

simultaneously with gonadotropins (Bastu et al., 2016). Six studies used letrozole (Bastu et

al., 2016; Haung et al., 2015; Mohsen et al., 2011b; Lee et al., 2011; Fauda & Sayed 2011;

Goswami et al., 2004) and three studies used clomiphene citrate (Revelli et al., 2014;

Karimzadeh et al., 2011; Mohsen et al., 2013a).

Urinary hCG was used for final oocyte maturation trigger in 10 studies, three studies used

recombinant hCG (Bastu et al., 2016; Kolibianakis et al., 2015; Kim et al., 2009), whereas it

was not reported in one study (Haung et al., 2015). Final follicular maturation was induced in

173

seven RCTs when at least two follicles were ≥ 18 mm (Goswami et al., 2004; Kim et al.,

2009; Karimzadeh et al., 2011; Mohsen et al., 2011b; Lee et al., 2011; Revelli et al., 2014;

Youssef et al., 2014), in five RCTs when at least two to three follicles were ≥ 17 mm

(Berkkanoglu & Ozgur 2010 ; Mohsen et al., 2011a; Fauda & Sayed 2011; Kolibianakis et al.,

2015; Bastu et al., 2016) while in two RCTs it was not reported clearly ( Klinkert et al., 2005;

Haung et al., 2015).

Follicle aspiration was performed 35-36 hours after hCG administration in all studies. In two

studies fertilization methods included IVF (Fouad & Sayed 2011; Klinkert et al., 2005), in five

studies ICSI (Bastu et al., 2016; Kolibianakis et al., 2015; Mohsen et al., 2011 a & b;

Berkkanoglu & Ozgur 2010),and in five studies IVF or ICSI (Revelli et al., 2014; Youssef et

al., 2014; Lee et al., 2011; Karimzadeh et al., 2011; Kim et al., 2009), whereas in two studies

details on fertilization were not available (Haung et al., 2015; Goswami et al., 2004).

Embryo transfers were performed on day 2 or 3 after oocyte retrieval in all included studies,

while luteal support varied among studies. Two studies did not provide details about the type

of luteal support (Haung et al., 2015; Lee et al., 2011).

Meta-analysis

Main comparison I: low doses of gonadotropins versus high doses of gonadotropins.

Six RCTs evaluated low doses of gonadotropins versus high doses of gonadotropins. We

pooled the data from four RCTs (Berkkanoglu & Ozgur 2010; Youssef et al., 2014; Bastu et

al., 2016; Kolibianakis et al., 2015). We did not pool the remaining two RCTs because there

was an overlap between what we defined as low and high doses of gonadotropins. (Klinkert

et al., 2005; Kim et al., 2009)

Pregnancy rates per woman randomized (Figure 2)

175

There was no evidence of a difference in ongoing pregnancy rate (3 RCTs: RR 1.05, (95% CI

0.66 to 1.65), I2=0%), clinical pregnancy rate (4 RCTs: RR 1.05, (95% CI 0.70 to 1.56; I2=0),

and live birth rate (2 RCTs: RR 1.49, (95% CI 0.49 to 4.51), I2=0%) between women treated

with low doses of gonadotropins or high doses of gonadotropins. This suggests that for a

woman with a 13% chance of achieving ongoing pregnancy with the use of high doses of

gonadotropins, the chance of an ongoing pregnancy with the use of low doses of

gonadotropins would be between 7% and 17%.

Total dose of gonadotropins required for ovarian stimulation

The total dose of gonadotropins required for ovarian stimulation was significantly decreased

in women who were treated with low doses of gonadotropins compared to those who were

treated with high doses of gonadotropins (3 RCTs. WMD -2222 IU, (95% CI -2985 to- 1459),

I2=99%). In all studies the mean dose of gonadotropins was lower in the low doses

gonadotropins intervention. Still, there was significant inconsistency in the mean difference

across trials as reflected by the I2 of 99%.

Duration of ovarian stimulation

There was no evidence of a difference in the duration required to complete ovarian

stimulation (3 RCTs. WMD -1.3 days, (95% CI -1.23 to 0.61), I2= 88%). There was significant

inconsistency in findings across trials as reflected by I2.

Cycle cancellation due to poor ovarian response

There was no evidence of difference in cycle cancellation rate between low doses and high

doses of gonadotropins (3 RCTs. RR 1.26, (95% CI: 0.91 to 1.74), I2=0%).

Laboratory outcomes

The low dose of gonadotropins resulted in a lower number of retrieved oocytes (3 RCTs.

WMD - 1.02 COC, (95% CI -1.83 to -0.22), I2=96), lower number of MII oocytes (3 RCTs.

WMD -0.94, (95% CI -1.42 to - 0.47), I2=87%) and lower number of embryos transferred (4

RCTs. WMD -0.1, (95% CI -0.19 to -0.01), I2=0%). There was no evidence of a difference in

the number of embryos obtained (3 RCTs. WMD 0.08, (95% CI -0.61 to 0.45), I2=85%)

between the women who were treated with low doses of gonadotropins and those who were

treated with high dose of gonadotropins. There was significant inconsistency in findings

across trials as reflected by I2.

176

Main comparison II: Gonadotropins combined with oral compounds versus gonadotropins.

Pregnancy rates per woman randomized (Figure 3)

178

There was no evidence of a difference in ongoing pregnancy rate (3 RCTs: RR 0.90, (95% CI

0.63 to 1.27), I2=0%) and clinical pregnancy rate (8 RCTs: RR 1.00, (95% CI 0.78 to 1.28),

I2=0%) women treated with gonadotropins combined with oral compounds and the

gonadotropins. No study reported on live birth rate. This suggests that for a woman with a

13% chance of achieving ongoing pregnancy with the use of gonadotropins, the chance of an

ongoing pregnancy with the use of gonadotropins combined with oral compounds would be

between 7 % and 16%.

Total dose of gonadotropins required for ovarian stimulation

The total dose of gonadotropins required for ovarian stimulation was significantly decreased

in women who were treated with gonadotropins combined with oral compounds when

compared with those who were treated with the gonadotropins (9 RCTs. WMD -2027 IU,

(95% CI -2583 to- 1470), I2= 98%). In all studies the mean dose of gonadotropins was lower

in the gonadotropins combined with oral compounds intervention. Still, there was significant

inconsistency in the mean difference across trials as reflected by the I2 of 98%.

Duration of ovarian stimulation

Significantly fewer days were required to complete ovarian stimulation in the women who

were treated with gonadotropins combined with oral compounds when compared with those

who were treated with gonadotropins (7 RCTs. WMD -1.79 days, (95% CI: -2.75 to -0.84),

I2=92%). There was significant inconsistency in findings across trials as reflected by I2.

Cycle cancellation due to poor ovarian response

Significantly more cycles were cancelled in the women who treated with gonadotropins

combined with oral compounds (7 RCTs. RR 1.61, (95% CI: 1.18 to 2.18), I2= 67%).

Laboratory outcomes

There was no evidence of a difference in the number of retrieved oocytes (9 RCTs. WMD -

0.5 COC, (95% CI: - 1.41 to 0.36) I2=91%), number of embryos obtained (6 RCTs. WMD 0.21

,(95% CI -0.42 to 0.84), I2=95%) and the number of embryos transferred (8 RCTs. WMD

2.25,(95% CI -0.69 to 5.18), I2=100%) between the women who were treated with

gonadotropins combined with oral compounds and those treated with the gonadotropins.

There was evidence of a difference in the number of MII oocytes (7 RCTs. WMD -0.78, (95%

CI -2.4 to -0.49), I2=88%). There was significant inconsistency in findings across trials as

reflected by I2.

179

Discussion

This systematic review and meta-analysis presents the most recent evidence on low dosing

of gonadotropins in women with poor ovarian reserve undergoing IVF/ICSI. We included

fifteen RCTs in the analysis, totalling 2183 women. Six studies compared low doses of

gonadotropins with high doses of gonadotropins. Nine studies compared gonadotropins

combined with letrozole or clomiphene citrate versus gonadotropins.

In the comparison between low and high doses of gonadotropins, we found no evidence of a

difference in pregnancy outcomes, duration of ovarian stimulation, cancellation rate of the

cycle and number of embryos obtained. On the other hand, there was an evidence of a lower

required dose of gonadotropins used and a lower number of oocytes retrieved, MII oocytes

obtained and embryos transferred.

In the comparison between gonadotropins combined with oral compounds and

gonadotropins, we found no evidence of a difference in pregnancy outcomes, number of

retrieved oocytes, number of embryos obtained and the number of embryos transferred. On

the other hand, there were less MII oocytes obtained and there was a higher cancellation

rate of the cycle, a shorter duration in administrating gonadotropins and less gonadotropins

used. Higher cycle cancellation rate does impose an extra burden compared to ovarian

stimulation with high doses, but it has been shown that low doses of gonadotropins protocols

have fewer side effects and stress related to hormone treatment and cycles cancellation

compared to high doses of gonadotropins (Højgaard et al., 2001; Klerk et al., 2005).

It is well known that as women age, not only oocyte quality decreases, but also oocyte

quantity and therefore, older women have fewer eggs to retrieve (Faddy & Gosden 1995;

Hansen et al., 2008). So, if the oocytes are not there, we can not harvest them, regardless of

the high doses of gonadotropins or types of GnRH analogues applied (Reindollar & Goldman

2012; Paulson et al., 2016). The lack of evidence of a difference in pregnancy rates between

low and high dosing of gonadotropins may be explained by a trade off between the positive

effects of low doses of gonadotropins on several biological processes, like improved embryo

quality, enhanced implantation, an increased proportion of euploid embryos and the negative

effects caused by high doses of gonadotropins via supraphysiological steroid levels on

endometrial receptivity (Hohmann et al., 2003; Baart et al., 2007; Devroey et al., 2004;

Beckers et al., 2006).

Several methodological considerations have to be taken into account when interpreting the

results. First, most included studies used computer generated randomization with a proper

method of allocation concealment. The quality of the studies varied from low to moderate to

180

high in some of larger studies. Sample size calculation was performed in 53% (8/15) of

included studies based on oocytes numbers in six studies (Bastu et al., 2016; Kolibianakis et

al., 2015; Haung et al., 2015; Revelli et al., 2014; Lee et al., 2011; Klinkert et al., 2005) and

pregnancy outcomes in two studies (Youssef et al., 2014; Fouda & Sayed 2011). Oocyte

number, as primary outcome, is not only an inadequate proxy for pregnancy chance but also

results in underpowered trials. Only 20% of studies (3/15) reported blinding of the clinician

and embryologist to the proposed intervention (Bastu et al., 2016; Fouda & Sayed 2011,

Goswami et al., 2004), Although we judged studies included in the analysis at low risk of

performance bias, as we considered it unlikely to influence outcomes, without blinding, the

staff managing the women could be prone to decision bias with respect to one intervention

over the other.

Second, there was significant clinical heterogeneity across studies due to differences

between women in their ovarian reserve and variations in the type and dosage of

gonadotropins and GnRH analogues. Before the establishment of Bologna criteria in 2011,

there was no universal definition of women with poor ovarian reserve or response (Ferraretti

et al., 2011). Bastu et al. (2016) and Haung et al. (2015) used the Bologna criteria for

including women, whereas other studies defined poor response based on different diagnostic

tests or patient characteristics. Third, there was little information concerning the number of

embryos cryopreserved and cumulative pregnancy rates which are variables directly related

to the comparison performed between the two strategies.

These methodological issues might at first glance represent a limitation of our findings, but

the clinical diversity of the analysed studies does ensure better generalizability of the results,

since the women included and the interventions studied mirror the real-world of clinical

practice.

To our knowledge, this is the first systematic review and meta-analysis specifically evaluating

ovarian stimulation with low dosing of gonadotropins in women with poor ovarian reserve.

We conclude that low doses of gonadotropins or gonadotropins combined with oral

compounds could be an alternative treatment options in women with poor ovarian reserve

undergoing ovarian stimulation for IVF.

Author’s roles

Youssef MA, van Wely M, Mochtar M, Fouda UM, and van der Veen F were responsible for

drafting the manuscript, YM and MW performed the data analysis. YM, MW, MM and FV

interpreted the data. YM, FU, FV, MW and MM contributed to the study design and data

acquisition. All authors critical revised the manuscript and agreed with the final version

181

Acknowledgements

None

Funding

None

Conflict of interest

None

182

References

• Baart EB, Martini E, Eijkemans MJ, Van Opstal D, Beckers NG, Verhoeff A, Macklon

NS, Fauser BC. Milder ovarian stimulation for in-vitro fertilization reduces aneuploidy

in the human preimplantation embryo: a randomized controlled trial. Hum Reprod

2007; 22:980-988.

• Bastu E, Buyru F, Ozsurmeli M, Demiral I, Dogan M, Yeh J. A randomized, single-

blind, prospective trial comparing three different gonadotropin doses with or without

addition of letrozole during ovulation stimulation in patients with poor ovarian

response. Eur J Obstet Gynecol Reprod Biol 2016; 203:30-34.

• Beckers NG, Platteau P, Eijkemans MJ, Macklon NS, de Jong FH, Devroey P, Fauser

BC. The early luteal phase administration of oestrogen and progesterone does not

induce premature luteolysis in normo-ovulatory women. Eur J Endocrinol 2006;

155:355-363.

• Berkkanoglu M, Ozgur K. What is the optimum maximal gonadotropin dosage used in

microdose flare-up cycles in poor responders. Fertil Steril 2010; 94:662-665.

• Bioroma 2014. Clomiphene Citrate Plus Gonadotropins and GnRH Antagonist Versus

Flexible GnRH Antagonist Protocol Versus Microdose GnRH Agonist Protocol in Poor

Responders Undergoing IVF. Identifier: NCT02201914. https://clinicaltrials.gov

• Bosdou JK, Venetis CA, Kolibianakis EM, Toulis KA, Goulis DG, Zepiridis L, Tarlatzis

BC. The use of androgens or androgen-modulating agents in poor responders

undergoing in vitro fertilization: a systematic review and meta-analysis. Hum Reprod

Update 2012; 18:127-45.

• Broer SL, van Disseldorp J, Broeze KA, Dolleman M, Opmeer BC, Bossuyt P,

Eijkemans MJ, Mol BW, Broekmans FJ; IMPORT study group. Added value of

ovarian reserve testing on patient characteristics in the prediction of ovarian response

and ongoing pregnancy: an individual patient data approach. Hum Reprod Update

2013; 19:26–36.

• Cedrin-Durnerin I, Bständig B, Hervé F, Wolf J, Uzan M, Hugues J. A comparative

study of high fixed-dose and decremental-dose regimens of gonadotropins in a

minidose gonadotropin-releasing hormone agonist flare protocol for poor responders.

Fertil Steril 2000; 73:1055-6.

183

• Clark JH, Markaverich BM. The agonistic-antagonistic properties of clomiphene: a

review. Pharmacol Ther 1981; 15:467-519.

• de Klerk C, Heijnen EM, Macklon NS, Duivenvoorden HJ, Fauser BC, Passchier J,

Hunfeld JA. The psychological impact of mild ovarian stimulation combined with

single embryo transfer compared with conventional IVF. Hum Reprod. 2006;21:721-7.

• Dercourt M, Barriere P, Freour T. High doses of gonadotropins for controlled ovarian

hyperstimulation: A case-control study. Gynecol Obstet Fertil 2016; 44:29-34.

• Devroey P, Bourgain C, Macklon NS, Fauser BC. Reproductive biology and IVF:

ovarian stimulation and endometrial receptivity. Trends Endocrinol Metab 2004;

15:84-90.

• Eftekhar M, Mohammadian F, Davar R, Pourmasumi S. Comparison of pregnancy

outcome after letrozole versus clomiphene treatment for mild ovarian stimulation

protocol in poor responders. Iran J Reprod Med 2014; 12:725-30.

• Faddy MJ1, Gosden RG. A mathematical model of follicle dynamics in the human

ovary. Hum Reprod 1995; 10:770-5.

• Ferraretti AP, La Marca A, Fauser BC, Tarlatzis B, Nargund G, Gianaroli L, ESHRE

Working Group on Poor Ovarian Response Definition. ESHRE consensus on the

definition of ‘poor response’ to ovarian stimulation for in vitro fertilization: the Bologna

criteria. Hum Reprod 2011; 26:1616–1624.

• Fondazione IRCCS Ca' Granda2011. Clomifene Citrate as First Line Treatment in in

Vitro Fertilization Cycles for Patients With Lower Ovarian Reserve (clomid). Identifier:

NCT01389713. https://clinicaltrials.gov.

• Fouda UM, Sayed AM. Extended high dose letrozole regimen versus short low dose

letrozole regimen as an adjuvant to gonadotropin releasing hormone antagonist

protocol in poor responders undergoing IVF-ET. Gynecol Endocrinol 2011; 27:1018-

22.

• Goswami SK, Das T, Chattopadhyay R, Sawhney V, Kumar J, Chaudhury K,

Chakravarty BN, Kabir SN. A randomized single-blind controlled trial of letrozole as a

low- cost IVF protocol in women with poor ovarian response: a preliminary report.

Hum Reprod 2004; 19:2031-5.

184

• Hansen KR, Knowlton NS, Thyer AC, Charleston JS, Soules MR, Klein NA. A new

model of reproductive aging: the decline in ovarian non-growing follicle number from

birth to menopause. Hum Reprod 2008; 23:699-708.

• Higgins JP1, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, Savovic J,

Schulz KF, Weeks L, Sterne JA; Cochrane Bias Methods Group; Cochrane Statistical

Methods Group. The Cochrane Collaboration's tool for assessing risk of bias in

randomised trials. BMJ 2011; 343:5928.

• Hohmann FP, Macklon NS, Fauser BC.A randomized comparison of two ovarian

stimulation protocols with gonadotropin-releasing hormone (GnRH) antagonist

cotreatment for in vitro fertilization commencing recombinant follicle-stimulating

hormone on cycle day 2 or 5 with the standard long GnRH agonist protocol. J Clin

Endocrinol Metab 2003; 88:166-73.

• Hofmann GE, Toner JP, Muasher SJ, Jones GS. High-dose follicle-stimulating

hormone (FSH) ovarian stimulation in low-responder patients for in vitro fertilization. J

In Vitro Fert Embryo Transf 1989; 6:285-9.

• Højgaard A, Ingerslev HJ and Dinesen J Friendly IVF: patient opinions. Hum Reprod

2001; 16:1391–1396

• Huang R, Wang B, Yang X, T. Li TT, and Liang XY: The comparison of mild

stimulation vs. controlled ovarian hyperstimulation protocol in poor ovarian

responders: a prospective randomized study. Hum Rep, 2015. 30. s49-50.

• Kamble L, Gaudi A, Shah A, Homburg R. Poor responders to controlled ovarian

hyperstimulation for in vitro fertilisation (IVF). Hum Fertil 2011; 14:230-45.

• Karimzadeh MA, Mashayekhy M, Mohammadian F, Moghaddam FM. Comparison of

mild and microdose GnRH agonist flare protocols on IVF outcome in poor

responders. Arch Gynecol Obstet 2011; 283:1159-64.

• Kim CH, Kim SR, Cheon YP, Kim SH, Chae HD, Kang BM. Minimal stimulation using

gonadotropin-releasing hormone (GnRH) antagonist and recombinant human follicle-

stimulating hormone versus GnRH antagonist multiple-dose protocol in low

responders undergoing in vitro fertilization/intracytoplasmic sperm injection. Fertil

Steril 2009;92:2082-4.

• Klinkert ER, Broekmans FJ, Looman CW, Habbema JD, te Velde ER. Expected poor

responders on the basis of an antral follicle count do not benefit from a higher starting

185

dose of gonadotrophins in IVF treatment: a randomized controlled trial. Hum Reprod

2005; 20:611-5.

• Kolibianakis EM, Venetis CA, Bosdou JK, Zepiridis L, Chatzimeletiou K, Makedos A,

Masouridou S, Triantafillidis S, Mitsoli A, Tarlatzis BC. Corifollitropin alfa compared

with follitropin beta in poor responders undergoing ICSI: a randomized controlled trial.

Hum Reprod 2015; 30:432-40.

• Kupka MS, Ferraretti AP, de Mouzon J, Erb K, D’Hooghe T, Castilla JA, Calhaz-Jorge

C, De Geyter C, Goossens V Assisted reproductive technology in Europe, 2010:

results generated from European registers by ESHRE. European IVF-Monitoring

Consortium, for the European Society of Human Reproduction and Embryology. Hum

Reprod 2014; 29:2099-113.

• Lee VC, Chan CC, Ng EH, Yeung WS, Ho PC. Sequential use of letrozole and

gonadotrophin in women with poor ovarian reserve: a randomized controlled trial.

Reprod Biomed Online 2011; 23:380-8.

• Lefebvre J, Antaki R, Kadoch IJ, Dean NL, Sylvestre C, Bissonnette F, Benoit J,

Menatd S, Lapensee L. 450 IU vs. 600 IU of gonadotropin for controlled ovarian

stimulation in poor responders: a randomized controlled trial. Fertil Steril 2015;

104:1419-25.

• Lekamge DN, Lane M, Gilchrist RB, Tremellen KP. Increased gonadotrophin

stimulation does not improve IVF outcomes in patients with predicted poor ovarian

reserve. J Assist Reprod Genet 2008; 25:515–21.

• Martin JA, Hamilton BE, Sutton PD, Ventura SV, Menacker F, Kimeyer S, Mathhews.

Births: Final data for 2006. National vital statistics reports; vol 57 no 7. Hyattsville,

MD: National Center for Health Statistics. 2009

• Masschaele T, Gerris J, Vandekerckhove F, De Sutter P. Does transferring three or

more embryos make sense for a well-defined population of infertility patients

undergoing IVF/ICSI? Facts Views Vis Obgyn 2012; 4:51-8.

• Mitwally MF, Casper RF. Aromatase inhibition improves ovarian response to follicle-

stimulating hormone in poor responders. Fertil Steril 2002; 77:776-80

• Mohsen IA, El Din RE. Minimal stimulation protocol using letrozole versus microdose

flare up GnRH agonist protocol in women with poor ovarian response undergoing

ICSI. Gynecol Endocrinol 2013; 29:105-8.

186

• Mohsen IA, Youssef MAFM, Elashmwi H, Darwish A, Mohesen MN, Khattab SM.

Clomiphene Citrate plus Modified GnRH Antagonist Protocol for Women with Poor

Ovarian Response Undergoing ICSI Treatment Cycles: Randomized Controlled Trial.

Gynecol Obstet 2013; 3:158.

• Morgia F, Sbracia M, Schimberni M, Giallonardo A, Piscitelli C, Giannini P, Aragona

C. A controlled trial of natural cycle versus microdose gonadotropin-releasing

hormone analog flare cycles in poor responders undergoing in vitro fertilization. Fertil

Steril 2004; 81:1542-7.

• National Institute for Health and Clinical Excellence. Updated NICE guidelines revise

treatment recommendations for people with fertility problems 2013 [CG156].

• Nargund G, Fauser BC, Macklon NS, Ombelet W, Nygren K, Frydman R, Rotterdam

ISMAAR Consensus Group on Terminology for Ovarian Stimulation for IVF. The

ISMAAR proposal on terminology for ovarian stimulation for IVF. Hum Reprod

2007;22:2801‑4.

• Oudendijk JF, Yarde F, Eijkemans MJ, Broekmans FJ, Broer SL. The poor responder

in IVF: is the prognosis always poor: a systematic review. Hum Reprod Update 2012;

18:1-11.

• Ozcan Cenksoy P, Ficicioglu C, Kizilkale O, Suhha Bostanci M, Bakacak M,

Yesiladali M, Kaspar C. The comparision of effect of microdose GnRH-a flare-up,

GnRH antagonist/aromatase inhibitor letrozole and GnRH antagonist/clomiphene

citrate protocols on IVF outcomes in poor responder patients. Gynecol Endocrinol

2014; 30:485-9

• Pandian Z, McTavish AR, Aucott L, Hamilton MP, Bhattacharya S. Interventions for

'poor responders' to controlled ovarian hyper stimulation (COH) in in-vitro fertilisation

(IVF). Cochrane Database Syst Rev 2010; 1:CD004379.

• Paulson RJ, Fauser BC, Vuong LT, Doody K. Can we modify assisted reproductive

technology practice to broaden reproductive care access? Fertil Steril 2016;

105:1138-43.

• Reindollar RH, Goldman MB. Gonadotropin therapy: a 20th century relic. Fertil Steril

2012; 97:813-8.

187

• Revelli A, Chiadò A, Dalmasso P, Stabile V, Evangelista F, Basso G, Benedetto C.

"Mild" vs. "long" protocol for controlled ovarian hyperstimulation in patients with

expected poor ovarian responsiveness undergoing in vitro fertilization (IVF): a large

prospective randomized trial. J Assist Reprod Genet 2014; 31:809-15.

• Royan institute 2015. Dual Ovarian Stimulation in the Same IVF/ICSI Cycles for

Treatment of Poor Ovarian Responders. Identifier: NCT02732808.

https://clinicaltrials.gov/

• Siristatidis CS, Hamilton MP. What should be the maximum FSH dose in IVF/ICSI in

poor responders? J Obstet Gynaecol 2007; 27:401-5.

• Sun Yat-sen University 2016. Tamoxifen and Clomiphene Citrate in Mild Stimulation

IVF. ClinicalTrials.govIdentifier:NCT02690870.

• Tarlatzis BC, Zepiridis L, Grimbizis G and Bontis J. Clinical management of low

ovarian response to stimulation for IVF: a systematic review. Hum Reprod Update

2003; 9:61–76.

• te Velde ER, Pearson PL. The variability of female reproductive ageing. Hum Reprod

Update 2002; 8:141-54.

• Yoo JH, Cha SH, Park CW, Kim JY, Yang KM, Song IO, Koong MK, Kang IS, Kim

HO. Comparison of mild ovarian stimulation with conventional ovarian stimulation in

poor responders. Clin Exp Reprod Med 2011; 38:159-63.

• Venetis CA, Kolibianakis EM, Tarlatzi TB, Tarlatzis BC. Evidence-based management

of poor ovarian response. Ann N Y Acad Sci 2010; 1205:199-206

• Youssef M, van Wely M, Al-inany H, Madani T, Jahangiri N, Khodabakhshi S, Rizk

AY, Alhalabi M, Almohamady M, Shaeer E, Aboulfoutouh I, Khattab S, Mochtar MH,

Van der Veen F. Mild versus standard ovarian stimulation in poor responder women

undergoing ivf and icsi (prima) – multicenter randomized controlled study. Hum Rep

2014:29:50, S1

188

Chapter 8

A mild ovarian stimulation strategy in women with poor ovarian reserve undergoing IVF: a multi-center randomized

non- inferiority trial

Youssef MA, van Wely M, Al-inany H, Madani T, Jahangiri N, S

Khodabakhshi S, Alhalabi M.Akhondi M , Ansaripour S ,

Tokhmechy R, Zarandi L, Rizk A, El-Mohamedy M, Shaeer E,

Khattab M2, Mochtar MH, van der Veen F.

Human Reproduction (accepted)

189

Abstract Study question: In subfertile women with poor ovarian reserve undergoing IVF does a mild

ovarian stimulation strategy lead to comparable ongoing pregnancy rates in comparison to a

conventional ovarian stimulation strategy?

Summary answer: A mild ovarian stimulation strategy in women with poor ovarian reserve

undergoing IVF leads to similar ongoing pregnancy rates as a conventional ovarian

stimulation strategy.

What is known already: Women today are having their babies later in life, when their fertility

has already declined. Many of these women seek medical help to become pregnant and

often have to rely on IVF. When diagnosed with poor ovarian reserve, they are treated with a

conventional ovarian stimulation strategy consisting of high-dose gonadotropins and pituitary

down regulation with a long mid-luteal start GnRH-agonist protocol. Whether this strategy is

more effective than a mild ovarian stimulation strategy consisting of low-dose gonadotropins

and pituitary down regulation with a GnRH-antagonist is unknown.

Study design, size and duration: This open-label multicenter randomized trial was

designed to compare one cycle of a mild ovarian stimulation strategy consisting of low-dose

gonadotropins (150 IU FSH) and pituitary down regulation with a GnRH-antagonist to one

cycle of a conventional ovarian stimulation strategy consisting of high-dose gonadotropins

(450 IU HMG) and pituitary down regulation with a long mid-luteal GnRH-agonist in women

of advanced maternal age and/or women with poor ovarian reserve undergoing IVF between

May 2011 and April 2014.

Participants/materials, setting, methods: Couples seeking infertility treatment were

eligible if they fulfilled the following inclusion criteria: female age ≥ 35 years, a raised basal

FSH level > 10 IU/ml irrespective of age, a low antral follicular count of ≤ 5 follicles or poor

ovarian response or cycle cancellation during a previous IVF cycle irrespective of age. The

primary outcome was ongoing pregnancy rate per woman randomized. Analyses were on an

intention-to-treat basis.

Main results and the role of change: We randomly assigned 195 women to the mild

ovarian stimulation strategy and 199 women to the conventional ovarian stimulation strategy.

Ongoing pregnancy rate was 12.8% (25/195) vs.13.6% (27 /199) leading to a RR of 0.95

(95% Confidence interval (CI) 0.57 to1.57), representing an absolute difference of minus

0.7% (95% CI - 7.4 to 5.9). This 95% confidence interval does not extend below the

predefined threshold of 10% for inferiority. The duration of ovarian stimulation was

significantly lower in the mild ovarian stimulation strategy than in the conventional ovarian

stimulation strategy (Mean difference -1.2 days, 95% CI -1.88 to -0.62). Also, a significantly

lower amount of gonadotropins was used in the mild simulation strategy, with a mean

difference of 3135 IU (95% CI -3331 to -2940).

190

Limitations, reasons for caution: A limitation of our study was the lack of data concerning

the cryopreservation of surplus embryos, so we are not informed on cumulative pregnancy

rates. Another limitation is that we were not able to follow up on the ongoing pregnancies in

all centers, so we are not informed on live birth rates.

Wider implications of the findings: The results are directly applicable in daily clinical

practice and may lead to considerable cost savings as high dosages of gonadotropins are

not necessary in women with poor ovarian reserve undergoing IVF. A health economic

analysis of our data planned to test the hypothesis that mild ovarian stimulation strategy is

more cost-effective than the conventional ovarian stimulation strategy is underway.

Study funding/competing interest(s): This study was supported by NUFFIC scholarship

(Netherlands) and STDF-short term fellowship (Egypt)

Trial registration number: NTR2788 (Trialregister.nl)

Trial registration date: 01 March 2011

Date of first patient’s enrolment: May 2011

Key words: mild ovarian stimulation/ poor ovarian reserve/ randomized

191

Introduction

The mean age of women giving birth to their first child in developed countries is still rising

(Schmidt et al., 2012; Martin et al., 2006; Rashed et al., 2005). As a result, more women face

subfertility due to diminished ovarian function who then seek medical help to become

pregnant (te Velde and Pearson, 2002). IVF is now the treatment of choice in older women

and it is estimated that 37% of all IVF cycles are performed in older women (NICE guidelines

2013; Kupka et al., 2010).

Poor ovarian reserve is a negative prognostic factor for success in IVF (Broer et al., 2013;

van Loendersloot et al., 2010). Data from ART–registers in the UK, Canada and Egypt

showed live birth rates per started cycle of 11.1%, 11.4% and 6.7% respectively in women

with poor ovarian reserve (Sunkara et al., 2011; Gunby et al., 2010; Serour et al., 2009).

Various stimulation protocols have been introduced to improve pregnancy outcomes in these

women. Traditionally, the stimulation protocol for women with poor ovarian reserve includes

high doses of FSH or HMG - up to 600 IU/day- which is very costly, but recently, protocols

with low dosages of gonadotropines have been introduced (Shanbhag et al., 2007;

Schimberni et al., 2008; Masschaele et al., 2012). Several studies have compared mild

ovarian stimulation consisting of low doses of gonadotropins or gonadotropins and co-

treatment by oral compounds with high doses of gonadotropins in IVF cycles (Cedrin-

Durnerin et al., 2000; D’Amato et al., 2004; Goswami et al., 2004; Morgia et al., 2004;

Klinkert et al., 2005; Kim et al., 2009; Berkkaoglu & Ozgur 2010; Madani et al., 2012; Hu et

al., 2014). These studies were either small RCTs, not powered to detect a difference in

ongoing pregnancy rates or were retrospective studies and do not allow for definite

conclusions. We therefore designed a large multicenter randomized clinical trial to compare

the effectiveness of a mild ovarian stimulation strategy versus a conventional ovarian

stimulation strategy in terms of ongoing pregnancy rate.

Materials and Methods

We performed a multinational, multicenter, open label, two arm, parallel group, randomized

controlled non-inferiority trial in 5 fertility centers. Full details of the trial protocol can be found

at www.studiesobsgyn. nl / prima.

All participants gave written informed consent. The study protocol was approved by the local

ethics committee at each participating center and was registered before its start with Clinical

trials identifier: NTR2788 (http://www.trialregister.nl/trialreg/admin/rctview). The protocol was

192

designed at the Academic Medical Center in the Netherlands and the trial was conducted in

several centers in Iran, Egypt and Syria between May 2011 and April 2014.

Couples seeking infertility treatment were eligible if they fulfilled one of the following inclusion

criteria: female age ≥ 35 years, a raised basal FSH level > 10 IU/ml irrespective of age, a low

antral follicular count of less than 5 follicles or poor ovarian response or cycle cancellation

during a previous IVF cycle irrespective of age. We defined poor ovarian response in a

previous cycle as an oocyte yield ≤ 5 (Ferraretti et al., 2011). Exclusion criteria were pre-

existing medical conditions, female age > 43 years, congenital uterine anomalies, polycystic

ovary syndrome and any other causes for anovulation.

Couples were randomly allocated in a 1: 1 ratio to receive either 150 IU of FSH in a GnRH

antagonist cycle or 450 IU of HMG in a mid-luteal long GnRH agonist protocol.

Randomization was performed with an online randomization program, stratified for study

center. A web based program generated a unique number with allocation code after entry of

the patient’s initials and date of birth. Neither the recruiters nor the trial project group could

access the randomization sequence. Blinding was not possible owing to the nature of the

interventions.

In women allocated to the mild ovarian stimulation strategy, pre-treatment with an oral

contraceptive pill was followed by ovarian stimulation starting with a fixed daily dose of

150IU/day follicle stimulating hormone (FSH) (Gonal-F®, Merck Serono, Fostimon, IBSA) on

day 5 after the last oral contraceptive pill and after establishing ovarian and uterine

quiescence using transvaginal ultrasound. 0.25 mg/day s.c. of a GnRH antagonist

(Cetrotide®, Merck Serono, Geneva, Switzerland or Orgalutran® MSD, Germany) was

commenced on stimulation day 6. Ovulation was triggered by 10000 IU human chorionic

gonadotropin hormone (Pregnyl, Schering- Plough Organon, Oss, The Netherlands,) when a

leading follicle reached 18 mm, and follicle aspiration was done by transvaginal ultrasound

guided oocyte retrieval 34-36 hours thereafter. Cycles were cancelled when there were no

ovarian response or < 2 follicles less than 15 mm after 7 days of ovarian stimulation.

Subsequently, embryo transfers was performed according to the local policy of participating

centers and two top quality embryos, were transferred on day 3. Transfer of more than 2

embryos was allowed when the women were more than 40 years old or had poor embryo

quality. The morphological score, the cell number, degree of fragmentation of the embryo

and the uniformity of the blastomeres were assessed daily. The embryos were given a score

of 1 (no fragmentation), 2 (< 20% fragmentation), 3 (20-50% fragmentation), or 4 (> 50 %

fragmentation) (Puissant et al., 1987). Top quality embryos were defined as embryos of

score 1 and 2 and poor quality embryos were defined as embryos of score 3 and 4. Embryo

transfer took place on day 3 after fertilization. Any remaining top -quality embryos were

cryopreserved and transferred after thawing in subsequent cycles until pregnancy was

193

achieved or all embryos had been transferred. Luteal phase support was with progesterone

suppositories (Cyclogest ®200mg, three times daily) or intramuscular administration

progesterone, starting on the day of follicle aspiration until a urine pregnancy test 17 days

later. In case of a positive pregnancy test, women were monitored with transvaginal

ultrasound at 5 to 6 weeks of amenorrhea to check whether an intrauterine gestational sac

was present. Subsequently, monitoring took place at 11 to 12 weeks amenorrhea to register

the presence of an intrauterine gestational sac with fetal heartbeat.

In the women allocated to the conventional ovarian stimulation strategy, daily injections were

given of 0.1 mg s.c of a gonadotropin releasing hormone agonist to prevent premature

ovulation, (Decapepetyl®, Ferring, Lucrin ®; Abbott) followed by stimulation with fixed daily

injections of 450 IU human menopausal gonadotropins hormone (HMG) (Menopur®,

Menogon® Ferring or Merional ®, IBSA). Ovulation was triggered by 10000 IU human

chorionic gonadotropins hormone (Pregnyl, Schering- Plough Organon, Oss, The

Netherlands) when a leading follicle reached 18 mm and follicle aspiration was done by

transvaginal ultrasound guided oocyte retrieval 34-36 hours thereafter. The remainder of the

cycle was identical to the mild ovarian stimulation strategy.

The primary outcome was ongoing pregnancy rate per randomised woman. An ongoing

pregnancy was defined as a viable pregnancy of at least 10-12 weeks of gestation.

Secondary outcomes included clinical pregnancy (any registered embryonic heart beat at

sonography), biochemical pregnancy (an increase in serum HCG or a positive pregnancy test),

multiple pregnancy (registered heartbeat of at least two foetuses at 6-8 weeks of gestation),

early pregnancy loss (loss of pregnancy before 12 weeks of gestations), number of oocytes

retrieved, number of metaphase II oocytes, fertilization rate, number of embryos obtained,

number of embryo transfers, total FSH/HMG doses used for ovarian stimulation, cancellation

rate, and drop-out rate.


The trial was designed to determine whether the mild ovarian stimulation strategy was non-

inferior to the conventional ovarian stimulation strategy, with a predefined non-inferiority

margin of 10%, meaning that the upper boundary of the 95% confidence interval of the

absolute difference between the primary endpoint in the two study groups would be lower

than 10%. We determined the sample size on the basis of an expected ongoing pregnancy

rate in the conventional strategy group of 20%. On basis of the chi-square statistic and

calculating with 80% power to detect the predefined non-inferiority margin at a one sided α

level of 0.05; we would need 177 women in each study group. Assuming a loss to follow-up

of 10%, the total study population was set at 394 people (197 per arm).

194

All randomized patients were included in all analyses according to the intention to treat

principle. We performed an additional per protocol analysis for our primary outcome. We

estimated differences in the binary outcomes as relative risks with 95% confidence intervals

using Fisher exact or Chi–square as appropriate. For continuous outcomes we calculated

means and standard deviations or medians with ranges and we evaluated differences with

Mann-Whitney U tests. We used SPSS (version 20.0) for all statistical analyses.

ResultsBetween May 2011 and April 2014, we included 394 couples; 195 couples were assigned to

the mild ovarian stimulation strategy and 199 to the conventional ovarian stimulation

strategy. Eleven women did not receive the allocated intervention and 15 women were lost to

follow up (Figure 1). Baseline characteristics in the two groups were similar in the two groups

(Table I).

Pregnancy outcomes are listed in table II. The primary outcome ongoing pregnancy was

12.8% (25/195) for women who received the mild ovarian stimulation strategy and13.6%

(27/199) for women who received the conventional ovarian stimulation strategy (RR 0.95;

95% CI 0.57 to 1.57), representing an absolute difference of minus 0.7% (95% CI - 7.4 to

5.9). This 95% confidence interval does not extend below the predefined threshold of 10%

for inferiority. Using a per protocol analysis, in the mild ovarian stimulation strategy 8 women

did not start treatment and 8 women dropped-out or were lost to follow up – this number was

10 in the conventional ovarian stimulation strategy , three women did not start treatment and

7 women dropped out or were lost to follow up. The ongoing pregnancy rate was 14.0%

(25/179) vs. 14.3% (27 /189) leading to a RR of 0.98 (95% CI 0.59 to 1.62), representing an

absolute difference of minus 0.3% (95% CI - 7.4 to 6.8). This 95% confidence interval does

not extend below the predefined threshold of 10% for inferiority.

Using logistic regression, we have evaluated the interaction for female age below and above

35 years of age and ongoing pregnancy rate. In women below 35 years of age there were 11

ongoing pregnancies in 61 women in the mild ovarian stimulation strategy and 12 ongoing

pregnancies in 66 women in the conventional ovarian stimulation strategy (RR: 0.99; 95% CI

0.47 to 2.0). In women above 35 years of age there were 14 ongoing pregnancies in 132

women in the mid ovarian stimulation strategy and 15 ongoing pregnancies in 130 women in

the conventional ovarian stimulation strategy (RR: 0.91; 95%CI 0.45 to 1.81). There was no

indication for interaction (P=0.79).

We found no evidence of any differences in rates of clinical pregnancy [15.3% (30/195)

versus. 15.5% (31/199)] (RR 0.86; 95% CI 0.55 to 1.34), early pregnancy loss [16.6% (5/30)

versus. 12.9% (4/31)] (RR 1.20; 95% CI 0.36 to 4.17), twin pregnancies [10% (3/30) versus.

22.5% (7/31)] (RR 0.41; 95% CI 0.10 to 1.65) and biochemical pregnancy [20% (39/195)

195

versus. 18% (36/199)] (RR 1.10; 95% CI 0.66 to 1.84). One ectopic pregnancy occurred in

each intervention arm.

Ovarian stimulation and laboratory outcomes are shown in Table III. The duration of ovarian

stimulation was significantly lower in the mild ovarian stimulation strategy (8.42, ± 2.89)

compared with the conventional ovarian stimulation strategy (9.67 ± 3.10) with a mean

difference of minus 1.2 days (95% CI -1.88 to - 0.62). Also a significantly lower amount of

gonadotropins was used in the mild ovarian simulation strategy, with a mean difference of

minus 3135 IU (95% CI -3331 to -2940).

In the mild ovarian stimulation strategy 52 (26%) cycles were cancelled and 37

(18%) cycles in the conventional ovarian stimulation strategy (RR 1.5; 95% CI 0.96

to 2.5). The mild ovarian stimulation strategy resulted in significantly fewer retrieved

oocytes compared to the conventional ovarian stimulation strategy. (Mean: 3.3, 95

% CI 2.3 to 4.0 vs. 5.0, 95% CI 4.3 to 5.5), fewer mature oocytes (MII) (Mean: 2.7,

95 % CI 2.4 to 3.2 vs. 4, 95% CI 3.4 to 4.5), fewer fertilized oocytes (Mean: 2.4,

95% CI 2.1 to 2.8 vs. 3.4, 95% CI 2.8 to 3.8), and fewer embryos (Mean: 2.0, 95 %

CI 1.8 to 2.5 vs. 2.7, 95% CI 2.3 to 3) but the number of good quality embryos

(Mean: 0.8, 95% CI 0.6 to 1.0 vs. 0.8, 95% CI 0.6 to 1.1) and embryos transferred

(Mean: 0.8, 95% CI 0.6 to 1.0 vs. 0.8, 95% CI 0.6 to 0.9) were similar.

196

Figu

re 1

:el

igib

ility,

rand

omiz

atio

n an

d fo

llow

–up

.

Elig

ible

cou

ples

(n=

520)

Assi

gned

to m

ild s

timul

atio

n st

rate

gy (n

=195

)As

sign

ed to

con

vent

iona

l stim

ulat

ion

stra

tegy

(n=1

99)

Rec

eive

d al

loca

ted

inte

rven

tion

(n=1

87)

Did

not

rece

ive

allo

cate

d in

terv

entio

n w

ith re

ason

s (n

= 8)

1 an

tago

nist

not

ava

ilabl

e,

1ha

dm

yom

a(e

xclu

sion

crit

eria

)1

with

drew

con

sent

1sp

onta

neou

s ov

ulat

ion

1no

ovar

ian

resp

onse

1fin

anci

al re

ason

2 re

ques

t sex

sel

ect io

n

32 w

omen

can

celle

d du

e to

poo

r ova

rian

resp

onse

2

conv

erte

d to

IUI d

ue to

low

resp

onse

11 n

o oo

cyte

s/M

II (3

) or f

ertil

izat

ion

failu

re (n

=8)

8lo

stto

follo

w-u

p/dr

op o

ut

Rec

eive

d al

loca

ted

inte

rven

tion

(n=1

96)

Did

not

rece

ive

allo

cate

d in

terv

entio

n w

ith re

ason

s (n

= 3)

1 us

ed fa

ult d

rug

1w

ithdr

ewco

nsen

t 1

no o

varia

n su

ppre

ssio

n

25 w

omen

can

celle

d du

e to

poo

r ova

rian

resp

onse

1 co

nver

ted

to IU

Idue

to lo

w re

spon

se7

no o

ocyt

es/M

II(2

)or f

ertil

izat

ion

failu

re (n

=5)

7w

omen

lost

to fo

llow

-up/

drop

out

Incl

uded

in th

e an

alys

is (n

=195

)In

clud

ed in

the

anal

ysis

(n=1

99)

Cou

ples

rand

omly

ass

igne

d to

trea

tmen

t (n=

394

)

Ref

used

topa

rtici

pate

(n=

126)

197

.

Tabl

e I:

Base

line

Cha

ract

eris

tics

of th

e co

uple

s*

Mild

ova

rian

stim

ulat

ion

stra

tegy

(N

=195

) C

onve

ntio

nal o

varia

n st

imul

atio

n st

rate

gy

(N=1

99)

Age

of fe

mal

e pa

rtner

, yea

rs

36.5

± 3

.936

.6 ±

4.3

Body

mas

s in

dex,

Kg/

m2

27.2

± 4

.427

.5 ±

5.3

Antra

l fol

licle

cou

nt (A

FC)

5.3

± 1.

66.

4 ±

2.9

Basa

l Fol

licle

stim

ulat

ing

horm

one

(FSH

), IU

/L11

.4 ±

4.3

10.5

± 4

.0

Basa

l Est

radi

ol, p

g/m

l43

.8 ±

22.

642

.8 ±

25.

7

Antim

ülle

rian

horm

one

(AM

H)*

, ng/

ml

0.5

± 0.

60.

6±0.

6

Med

ian

(IOR

) dur

atio

n of

tim

e at

tem

ptin

g to

con

ceiv

e, y

ears

9.

0 (6

.0 -

13)

8.5

(4.0

-13

.2)

Prim

ary

infe

rtilit

y, n

(%)

143

(73)

138

(70)

Prev

ious

IVF/

ICSI

cyc

les,

n (%

)89

(45)

94 (4

8)

*Pl

us–m

inus

val

ues

are

mea

ns ±

SD.

* Antim

ülle

rian

horm

one

(AM

H) w

as m

easu

red

in n

/N (%

) of t

he p

atie

nts

198

Tabl

e II:

Preg

nanc

y ou

tcom

es

Out

com

eM

ild o

varia

n st

imul

atio

n st

rate

gy

(N=1

95)

Con

vent

iona

l ova

rian

stim

ulat

ion

stra

tegy

(N

=199

)

RR

(95%

CI)

Ong

oing

pre

gnan

cy ≥

12

wee

ks -

no. o

f wom

en (%

)25

(12.

8)27

(13.

5)0.

91 (0

.50

-1.6

4)

Clin

ical

pre

gnan

cy -

no. o

f wom

en (%

)30

(15.

3)31

(15.

5)0.

86 (0

.55

-1.3

4)

Early

pre

gnan

cy lo

ss-n

o. o

f wom

en/to

tal n

o. o

f clin

ical

pre

gnan

cies

(%)

5.0

(16.

6)4.

0 (1

2.9)

1.20

(0.3

6 -4

.17)

Twin

pre

gnan

cy -

no. o

f wom

en/to

tal n

o. o

f clin

ical

pre

gnan

cies

(%)

3.0

(10)

7.0

(22.

5)0.

41 (0

.10

-1.6

5)

Con

cept

ion

(pos

itive

βhC

G) -

no. o

f wom

en (%

)39

(20)

36 (1

8.0)

1.10

(0.6

6 -1

.84)

199

Tabl

e III

: ova

rian

stim

ulat

ion

and

labo

rato

ry o

utco

mes

Out

com

eM

ild o

varia

n st

imul

atio

n st

rate

gy (N

=195

)C

onve

ntio

nal o

varia

n st

imul

atio

n st

rate

gy (N

=199

)R

R (9

5% C

I)M

D (9

5% C

I)

Dur

atio

n of

ova

rian

stim

ulat

ion,

day

s8.

4 ±

2.9

9.7

± 3.

1-1

.2 (-

1.88

to -0

.62)

Tota

l am

ount

of g

onad

otro

pins

, IU

1436

± 5

5244

72 ±

115

6-3

135

(-33

31 to

-29

40)

Cyc

le c

ance

llatio

n -n

o. (%

)52

(26.

6)37

(18.

6)1.

5 ( 0

.96

-2.5

)

No.

ooc

ytes

retri

eved

, (m

edia

n)3.

3 ±

3.5

(2)

(95

% C

I 2.3

to 4

)

5.0

± 4

(4)

(95%

CI 4

.3 to

5.5

)

-1.6

(-2.

5 to

-.89

)

No.

MII

oocy

tes,

(med

ian)

2.7

±2.

6 (2

)

(95

% C

I 2.4

to 3

.2)

4.0±

3.6

(3)

(95%

CI 3

.4 to

4.5

)

-1.3

(-2.

0 to

-0.6

9)

No.

ferti

lized

ooc

ytes

2.

4 ±

2

(95%

CI 2

.1 to

2.8

)

3.4

± 3

(95%

CI 2

.8 to

3.8

)

-1.0

(-1.

6 to

-.47

)

No.

em

bryo

s ob

tain

ed, (

med

ian)

2.0

± 1.

9 (2

)

(95

% C

I 1.8

to 2

.5)

2.7

± 2.

4 (2

)

(95%

CI 2

.3 to

3)

-.72

(-1.2

to -.

22)

No.

top

qual

ity e

mbr

yos,

(med

ian)

0.8

± 1.

1 (0

.00)

(95%

CI 0

.6 to

1.0

)

0.8

± 1.

2 (0

.00)

(95%

CI 0

.6 to

1.1

)

-.08

(-.41

to .2

4)

No.

em

bryo

s tra

nsfe

rred,

(med

ian)

0.8

± 1.

3 (2

)

(95%

CI 0

.6 to

1.0

)

0.8

±1.

2 (2

)

(95%

CI 0

.6 to

0.9

)

-.19

(-.48

to 0

.09)

Plus

–min

us v

alue

s ar

e m

eans

±SD

200

Discussion

In this clinical trial, involving women with poor ovarian reserve, a mild ovarian stimulation

strategy did not lead to less ongoing pregnancies compared to a conventional ovarian

stimulation strategy, but the mild ovarian stimulation strategy yielded a nearly 3000 IU

reduction in use of gonadotropins per woman. We found no differences in ovarian stimulation

results such as number of embryos transferred and their quality, except for a lower number

of retrieved oocytes, MII oocytes fertilized oocytes and embryos obtained in the mild ovarian

stimulation strategy.

The strength of this study lies in the comparison between two strategies of ovarian

stimulation in women with poor ovarian reserve in a well powered and large multicenter

international RCT with central randomization comparing, for the first time, the lowest dose of

FSH ever used in a GnRH antagonist protocol, with conventional ovarian stimulation with

high dosages of 450 IU of HMG. In addition, the dose of the gonadotropins was not

increased or decreased throughout the stimulation phase. We achieved excellent success

rates with this strategy in women traditionally associated with poor reproductive outcome,

casting reasonable doubt on the utility of high doses of gonadotropins (Land et al., 1996).

The choice of our strategies may warrant some discussion. The whole purpose of the trial

was not to simply compare two dosages of FSH, but to compare the best and clinically most

relevant strategies, in which one strategy would use less gonadotropin than currently

customary in women with poor ovarian reserve.

To achieve the best possible mild ovarian stimulation strategy we chose dual pituitary

suppression for our mild ovarian stimulation strategy, because pretreatment with oral

contraceptive pills in GnRH antagonist protocols has been proven to achieve better

scheduling of the stimulation cycle, to prevent early endogenous FSH rise, to reduce the

amount and duration of gonadotropins required for follicular maturation, to improve follicular

homogeneity and to generate chromosomally normal embryos by reduced interference with

ovarian physiology (Huirne et al.; 2006; Van Blerkom et al 2001; Baart et al. 2007).

To achieve the best possible conventional ovarian stimulation strategy we used HMG since

the addition of an LH-like component to FSH in a long GnRH agonist protocol may increase

ongoing pregnancy rates in especially in women with poor ovarian reserve (Van Wely et al.,

2011, Mochtar et al., 2007).

201

Although we designed our study protocol before the release of Bologna criteria, when there

was no consensus on the definition of women with poor ovarian reserve or poor ovarian

response, our women posthoc do fulfill the Bologna criteria which reduces bias caused by

spurious definitions of poor responders, allowing to draw reliable conclusions (Ferraretii et

al., 2011). The trial was further strengthened by our primary outcome, the ongoing pregnancy

rate.

A limitation of our study was the lack of data concerning the cryopreservation of surplus

embryos, so we are not informed on cumulative pregnancy rates. Another limitation is that

we were not able to follow up on the ongoing pregnancies in all centers, so we are not

informed on live birth rates. An inference on this can be made by data from a recently

published trial on individualized gonadotropin dosing in predicted poor responders, which

shows that individualized dosing does not influence live birth rates or time to pregnancy

(Tilborg et al., 2016). Open label nature of the study could be considered as a source of bias.

Blinding was not possible for the type of intervention, but we consider it unlikely that blinding

would affect pregnancy outcome for the comparisons under study.

Furthermore, the different downregulation protocols - GnRH antagonist vs. long GnRH

agonist- could be considered to represent a flaw in the study design. Three meta-analyses

compared GnRH antagonist with GnRH agonist protocols in poor responders and showed no

differences in the number of retrieved oocytes, mature oocytes, cycle cancellation rate or

clinical pregnancy rate or pregnancy rate (Pu et al., 2011; Al-inany et al., 2011; Xiao et al.

2013).

Our results are contributing more data in the form of a RCT to existing information and are in

line with three randomized clinical trials that evaluated mild ovarian stimulation in women

with poor ovarian reserve (Klinkert et al., 2005; Revelli et al., 2014; Bastu et al., 2016). The

first study entailed 52 women with AFC ˂ 5 follicles before starting their first IVF cycle, and

compared 150 IU of rec.FSH to a fixed daily dose of 300 IU rec. FSH (Klinkert et al., 2005).

The second study entailed 695 women with expected poor ovarian response compared a

mild stimulation protocol 100 mg/day Clomiphene citrate followed by 150 IU HMG combined

with a GnRH antagonist to a conventional stimulation protocol with daily 300 IU HMG

combined with a GnRH agonist. There was no difference in ongoing pregnancy rates, but

there were more oocytes and embryos in the conventional strategy (Revelli et al., 2014). In

the third RCT, entailing 95 women found no difference in pregnancy rates between women

receiving 150 FSH/HMG combined with letrozole in a fixed GnRH antagonist protocol and

women receiving either 300 or 450 IU FSH/HMG (Bastu et al., 2016).

202

When applied in daily clinical practice the data generated by this trial may lead to

considerable cost savings as high dosages of gonadotropins are not necessary in women

with poor ovarian reserve undergoing IVF. A cost effectiveness analysis to prove or refute

this hypothesis is underway.

In conclusion, a mild ovarian stimulation strategy is non-inferior to conventional ovarian

stimulation in terms of the ongoing pregnancy rates and is associated with shorter duration of

stimulation, lower amount of gonadotropins and less costs required for ovarian stimulation.

Thus, mild ovarian stimulation should be the treatment of choice in women with poor reserve

undergoing IVF

Acknowledgements

The authors thank all the doctors and nurses at the participating sites, and especially the

women who participated in this study

Authors’ roles

Mohamed AF. Youssef, Madelon van Wely, Hesham G. Al-inany, Monique Mochtar and

Fulco van der Veen initiated and conceptualised the protocol. Mohamed AF. Youssef,

Tahereh Madani, Nadia Jahangiri , Shabnam Khodabakhshi , Ahmed Y. Rizk, Marwan

Alhalabi , Mohammad-Mehdi Akhondi, Soheila Ansaripour , Reihaneh Tokhmechy , Leila

Karimi Zarandi, Maged R. El-Mohamedy , Eman K. Shoair , Sherif M. Khattab, undertook

patient recruitment and data collection , Mohamed AF. Youssef, Madelon van Wely

performed the analyses of the data. All authors participated in the interpretation of the data

and writing of the final version

Funding

This study was supported by NUFFIC scholarship (Netherlands) and STDF-short term

fellowship (Egypt, project number: 5445)

Conflict of interest

The authors have no conflict of interest to declare

203

References

• Al-Inany HG, Youssef MA, Aboulghar M, Broekmans F, Sterrenburg M, Smit J, Abou-Setta AM. Gonadotrophin-releasing hormone antagonists for assisted reproductive technology. Cochrane Database Syst Rev. 2011 ;( 5) CD001750.

• Amsterdam A, Hanoch T, Dantes A, Tajima K, Strauss JF, Seger R. Mechanisms of gonadotropin desensitization. Mol Cell Endocrinal. 2002; 187:69–74.

• Bastu E, Buyru F, Ozsurmeli M, Demiral I, Dogan M, Yeh J. A randomized, single-blind, prospective trial comparing three different gonadotropin doses with or without addition of letrozole during ovulation stimulation in patients with poor ovarian response. Eur J Obstet Gynecol Reprod Biol. 2016; 203:30-34.

• Berkkanoglu M, Ozgur K. What is the optimum maximal gonadotropin dosage used in microdose flare-up cycles in poor responders. Fertil Steril. 2010; 94:662-5.

• Broer SL, van Disseldorp J, Broeze KA, Dolleman M, Opmeer BC, Bossuyt P, Eijkemans MJ, Mol BW, Broekmans FJ; IMPORT study group. Added value of ovarian reserve testing on patient characteristics in the prediction of ovarian response and ongoing pregnancy: an individual patient data approach. Hum Reprod Update 2013; 19:26–36.

• Cedrin-Durnerin I, Bständig B, Hervé F, Wolf J, Uzan M, Hugues J. A comparative study of high fixed-dose and decremental-dose regimens of gonadotropins in a minidose gonadotropin-releasing hormone agonist flare protocol for poor responders. Fertil Steril. 2000; 73:1055-6.

• D’Amato G, Caroppo E, Pasquadibisceglie A, Carone D, Vitti A, Vizziello GM. A novel protocol of ovulation induction with delayed gonadotrophin-releasing hormone antagonist administration combined with high-dose recombinant follicle-stimulating hormone and clomiphene citrate for poor responders and women over 35 years. Fertil Steril. 2004; 81: 1572–7.

• Ferraretti AP, La Marca A, Fauser BC, Tarlatzis B, Nargund G, Gianaroli L, ESHRE Working Group on Poor Ovarian Response Definition. ESHRE consensus on the definition of ‘poor response’ to ovarian stimulation for in vitro fertilization: the Bologna criteria. Hum Reprod. 2011; 7:1616–1624.

• Goswami SK, Das T, Chattopadhyay R, Sawhney V, Kumar J, Chaudhury K, Chakravarty BN, Kabir SN. A randomized single-blind controlled trial of letrozole as a low- cost IVF protocol in women with poor ovarian response: a preliminary report. Hum Reprod. 2004; 19:2031-5.

• Gunby J, Bissonnette F, Librach C, Cowan L; IVF Directors Group of the Canadian Fertility and Andrology Society . Assisted reproductive technologies (ART) in Canada: 2007 results from the Canadian ART Register. Fertil Steril. 2011; 2:542-7.

204

• Hu L, Bu Z, Guo Y, Su Y, Zhai J, Sun Y. Comparison of different ovarian hyperstimulation protocols efficacy in poor ovarian responders according to the Bologna criteria. Int J Clin Exp Med. 2014; 4:1128-34.

• Huirne JA, Hugues JN, Pirard C,Fischl F, Sage JC, Obruca A, Braat DM, van Leonen AC, Lambalk CB. Cetrorelix in an oral contraceptive-pretreated stimulation cycle compared with buserelin in IVF/ICSI patients treated with r-hFSH: a randomized, multicentre, phase IIIb study. Hum Reprod. 2006; 6:1408-15.

• Kim CH, Kim SR, Cheon YP, Kim SH, Chae HD, Kang BM. Minimal stimulation using gonadotropin-releasing hormone (GnRH) antagonist and recombinant human follicle-stimulating hormone versus GnRH antagonist multiple-dose protocol in low responders undergoing in vitro fertilization/intracytoplasmic sperm injection. Fertil Steril. 2009; 92:2082-4.

• Klinkert ER, Broekmans FJ, Looman CW, Habbema JD, te Velde ER. Expected poor responders on the basis of an antral follicle count do not benefit from a higher starting dose of gonadotrophins in IVF treatment: a randomized controlled trial. Hum Reprod. 2005; 20:611-5.

• Kupka MS, Ferraretti AP, de Mouzon J, Erb K, D’Hooghe T, Castilla JA, Calhaz-Jorge C, De Geyter C, Goossens V Assisted reproductive technology in Europe, 2010: results generated from European registers by ESHRE. European IVF-Monitoring Consortium, for the European Society of Human Reproduction and Embryology. Hum Reprod. 2014; 10:2099-113.

• Land JA, Yarmolinskaya MI, Dumoulin JC, Evers JL. High-dose human menopausal gonadotropin stimulation in poor responders does not improve in vitro fertilization outcome. Fertil Steril. 1996; 65:961–5.

• Lekamge DN, Lane M, Gilchrist RB, Tremellen KP. Increased gonadotrophin stimulation does not improve IVF outcomes in patients with predicted poor ovarian reserve. J Assist Reprod Genet. 2008; 25:515–21.

• Madani T, Ashrafi M, Yeganeh LM. Comparison of different stimulation protocols efficacy in poor responders undergoing IVF: a retrospective study. Gynecol Endocrinol. 2012; 28:102-5

• Martin JA, Hamilton BE, Sutton PD, Ventura SV, Menacker F, Kimeyer S. Births: Final data for 2004. Nati Vital Stati Rep. 2006; 55: 1-101,

• Masschaele T, Gerris J, Vandekerckhove F, De Sutter P. Does transferring three or more embryos make sense for a well-defined population of infertility patients undergoing IVF/ICSI? Facts Views Vis Obgyn. 2012; 1:51-8.

• Mochtar MH, Van der Veen, Ziech M, van Wely M. Recombinant Luteinizing Hormone (rLH) for controlled ovarian hyperstimulation in assisted reproductive cycles. Cochrane Database Syst Rev. 2007; 2 (CD005070).

• Morgia F, Sbracia M, Schimberni M, Giallonardo A, Piscitelli C, Giannini P, Aragona C. A controlled trial of natural cycle versus microdose gonadotropin-releasing

205

hormone analog flare cycles in poor responders undergoing in vitro fertilization. Fertil Steril. 2004; 81:1542-7.

• National Institute for Health and Clinical Excellence (2013) Updated NICE guidelines revise treatment recommendations for people with fertility problems. NICE guidelines [CG156]

• Pu D, Wu J, Liu J. Comparisons of GnRH antagonist versus GnRH agonist protocol in poor ovarian responders undergoing IVF. Hum Reprod. 2011; 26(10):2742-9

• Puissant F, Van Rysselberge M, Barlow P, Deweze J, Leroy F. Embryo scoring as a prognostic tool in IVF treatment. Hum Reprod 1987; 8:705–708.

• Rashad H, Osman M, and Roudi-Fahimi F, Marriage in the Arab World: Population reference bureau 2005.

• Revelli A, Chiadò A, Dalmasso P, Stabile V, Evangelista F, Basso G, Benedetto C. "Mild" vs. "long" protocol for controlled ovarian hyperstimulation in patients with expected poor ovarian responsiveness undergoing in vitro fertilization (IVF): a large prospective randomized trial. J Assist Reprod Genet. 2014; 7:809-15.

• Schimberni M, Morgia F, Colabianchi J, Giallonardo A, Piscitelli C, Giannini P, Montigiani M, Sbarcia M. Natural-cycle in vitro fertilization in poor responder patients: a survey of 500 consecutive cycles. Fertil Steril. 2009; 4:1297-301

• Schmidt DW, Bremner T, Orris JJ, Maier DB, Benadiva CA, Nulsen JC. A randomized prospective study of micro dose leuprolide versus ganirelix in in vitro fertilization cycles for poor responders. Fertil Steril 2005; 83:1568–71.

• Serour G, Mansour R, Serour A, Aboulghar M, Amin Y, Kamal O, Al-Inany H, Aboulghar M. Analysis of 2,386 consecutive cycles of in vitro fertilization or intracytoplasmic sperm injection using autologous oocytes in women aged 40 years and above. Fertil Steril. 2010; 5:1707-12.

• Shanbhag S, Aucott L, Bhattacharya S, Hamilton MA, McTavish AR. Interventions for 'poor responders' to controlled ovarian hyperstimulation (COH) in in-vitro fertilisation (IVF). Cochrane Database Syst Rev. 2007; (1): CD004379.

• Sunkara SK, Rittenberg V, Raine-Fenning N, Bhattacharya S, Zamora J, Coomarasamy A. Association between the number of eggs and live birth in IVF treatment: an analysis of 400 135 treatment cycles. Hum Reprod. 2011; 7:1768-74.

• te Velde ER, Pearson PL. The variability of female reproductive ageing. Hum Reprod Update. 2002; 2:141-54.

• Tilborg CV, Oudshoorn SC, Eijkemans M.J.C, Manger P.A.P, Brinkhuis E , van Heusden A.M., Kuchenbecker W.K.H, Smeenk J.M.J, Kwee J, Verhoeve H.R,Lambalk C.B, van der Veen F, Mol B.W.J , Torrance H.L, Broekmans F.J.M.Optimization of outcome through individualized dosing in predicted poor responders undergoing IVF/ICSI; the OPTIMIST randomized controlled trial. Hum Reprod. The 23nd Annual Meeting of ESHRE, Helsinki, Finland, 3 July-6 July, 2016, O-35.

206

• Van Blerkom J, Davis P. Differential effects of repeated ovarian stimulation on cytoplasmic and spindle organization in metaphase II mouse oocytes matured in vivo and in vitro. Hum Reprod 2001; 16:757–64

• van Loendersloot LL, van Wely M, Limpens J, Bossuyt PM, Repping S, van der Veen F. Predictive factors in in vitro fertilization (IVF): a systematic review and meta-analysis. Hum Reprod Update. 2010; 6:577–589.

• Xiao JS, Su CM, Zeng XT. The effectiveness of gonadotropin-releasing hormone antagonist in poor ovarian responders undergoing in vitro fertilization: a systematic review and meta-analysis Fertil Steril. 2013; 100:1594-601.

207

Chapter 9

Summary

208

Subfertility is defined as a failure to conceive after at least one year of regular unprotected

intercourse (Zegers-Hochschild et al., 2009). It affects approximately 10% of couples in their

reproductive lives (Boivin et al., 2007). The introduction of medically assisted reproduction

(MAR) has provided millions of couples with hope. MAR consists of ovulation induction,

intrauterine insemination (IUI) with or without ovarian stimulation, and in vitro fertilization

(IVF) with or without assisted fertilization (ICSI).

In IVF, ovarian stimulation with gonadotropins is an integral part of the treatment. It has been

introduced with the aim of increasing the number of embryos to compensate for poor embryo

quality, but is now being used to enable the selection of the best embryo for fresh transfer

and the cryopreservation of surplus embryos (Fauser et al., 2005). Stimulation protocols

involving high doses of exogenous gonadotropins, combined with gonadotropin releasing

hormone (GnRH) analogues for the prevention of premature LH peaks are the most

frequently used protocols (Macklon et al., 2006).

The oocyte yield after these protocols depends on the follicle pool. In women with a normal

or an elevated ovarian reserve, high doses can provoke an excessive ovarian response with

subsequent ovarian hyperstimulation syndrome (OHSS).

As the treatment of OHSS involves supportive management while the condition slowly

improves, the mainstay of management of women at risk of OHSS resolves around the

prevention of this complication in the first instance. Several preventive approaches have

been suggested to reduce the risk of OHSS. Primary prevention includes individualized

ovarian stimulation protocols with mild doses of gonadotropins (Heijnen et al., 2007; Rinaldi

et al., 2014), use of GnRH antagonists (Onofriescu et al., 2013) and in vitro maturation (Yu et

al., 2012). Secondary prevention includes all strategies directed to counteract an excessive

ovarian response, i.e. cycle cancellation (Rizk & Aboulghar 1991), coasting (D'Angelo et

al.,2011), ovulation triggering by low doses of HCG (Tiboni et al.,2016) or by a GnRH agonist

(Casper RF 2015), dopamine agonist administration around the time of follicle aspiration

(Baumgarten et al., 2013); intravenous volume expanders administration at the time of follicle

aspiration (Gokmen et al., 2001) and cryopreservation of oocytes or embryos (Boothroyd et

al., 2015).

In women with a poor response to ovarian stimulation, like women of advanced female age,

there is a physiologic decline in ovarian reserve of primordial follicles (de Boer et al., 2004).

In young women a poor response to ovarian stimulation reflects a pathologic decline in

number and quality of primordial follicles. Currently, the conventional ovarian stimulation

regimen for women with poor ovarian reserve includes high doses of FSH or HMG combined

with various protocols of GnRH analogues to try and achieve high follicular recruitment

209

(Bosdou et al., 2012). Nevertheless, despite these high doses of gonadotropins, oocyte yield

remains poor and cancellation rates are high (Dercourt et al., 2016).

In this thesis, we set out to perform a series of systematic reviews and meta-analyses to

evaluate the most widely used pharmacologic interventions for the prevention of OHSS like

the use of GnRH antagonists, dopamine agonist supplementation, GnRH agonist trigger for

final oocyte maturation trigger and intravenous fluid administration. We a set out to perform a

randomized controlled trial evaluating the lowest possible dose of cabergoline in two hundred

women at risk to develop OHSS.

On the other end of the spectrum of ovarian response, we designed a multicentre

randomized controlled trial to explore the possible beneficial effect of mild ovarian stimulation

in women with poor ovarian reserve undergoing IVF, defined as women with a female age ≥

35 years, a raised basal FSH level > 10 IU/ml irrespective of age, a low antral follicular count

of less than 5 follicles or poor ovarian response or cycle cancellation during a previous IVF

cycle irrespective of age. Finally, we systematically summarized randomized controlled trials

comparing low doses of gonadotropins in ovarian stimulation regimens in women with poor

ovarian reserve to high doses of gonadotropins in terms of ongoing pregnancy rate per fresh

IVF attempt.

In chapter 1 we provide a general introduction of this thesis and describe the objectives of

this thesis.

In chapter 2 we present the update of a Cochrane systematic review -first published in 2001,

and previously updated in 2006 and 2011- that assesses the effectiveness and safety of

pituitary downregulation by GnRH antagonists compared to the standard long protocol of

GnRH agonists as part of ovarian stimulation regimens in assisted conception cycles. GnRH

antagonists prevent a luteinizing hormone (LH) surge during stimulation without the hypo-

estrogenic side-effects, flare-up phenomenon, or long period of down-regulation associated

with GnRH agonists. The antagonists directly and rapidly inhibit gonadotropin release within

several hours through competitive binding to pituitary GnRH receptors. This property allows

their use at any time during the follicular phase. Women receiving antagonists have been

shown to have a lower incidence of OHSS. Assuming comparable clinical outcomes for the

antagonist and agonist protocols, these benefits would justify a change from the standard

long agonist protocol to antagonist regimens.

Thus, we searched the Medline, EMBASE, Cochrane database, Psyc INFO, CINHAL, Trials

registers for ongoing and registered trials, DARE, LILACS database and OpenGrey, from

inception until April 2015. We included randomized controlled trials comparing GnRH

210

antagonist protocols versus long GnRH agonists protocols in women undergoing in vitro

fertilisation (IVF) or intracytoplasmic sperm injection (ICSI). Primary outcome measure of

effectiveness was live birth rate and primary outcome measure of safety was OHSS.

Secondary outcome measures were ongoing pregnancy rate, clinical pregnancy rate,

miscarriage rate and cycle cancellation rate. We retrieved 479 records after removal of

duplicates, excluded 399 as ineligible, and assessed 80 full-text articles. Of these, we

excluded 51 and included 28 (29 reports) studies in the update, in addition to the 45 studies

from the 2011 review. We thus included seventy-three randomised controlled studies,

involving 12,212 randomised women.

There was no evidence of a difference in live birth rate between GnRH antagonists and

agonists (OR 1.02, 95% CI 0.85 to 1.23; 12 RCTs, 2303 women, I2 = 27%, moderate quality

evidence). The evidence suggested that if the chance of live birth following GnRH agonist is

assumed to be 29%, the chance following GnRH antagonist would be between 25% and

33%, GnRH antagonists were associated with a lower incidence of any grade of OHSS than

GnRH agonists (OR 0.61, 95% C 0.51 to 0.72; 36 RCTs, 7944 women, I2 = 31%, moderate

quality evidence). The evidence suggested that if the risk of OHSS following GnRH agonist is


There was no evidence of a difference in miscarriage rate per woman randomised between

GnRH antagonists and agonists (OR 1.03, 95% CI 0.82 to 1.29; 34 RCTs, 7082 women, I2 =

0%, moderate quality evidence). With respect to cycle cancellation, GnRH antagonists were

associated with a lower incidence of cycle cancellation to prevent OHSS (OR 0.47, 95% CI

0.32 to 0.69; 19 RCTs, 4256 women, I2 = 0%). Cycle cancellation due to poor ovarian

response was higher in women who received GnRH antagonists than those who were

treated with GnRH agonists (OR 1.32, 95% CI 1.06 to 1.65; 25 RCTs, 5230 women, I2 =

68%; moderate quality evidence). We conclude that the use of GnRH antagonists compared

with long-course GnRH agonist protocols is associated with a substantial reduction in OHSS

without reducing the likelihood of achieving live birth.

In chapter 3 we give the results of a randomized controlled trial that investigated the

effectiveness and safety of a low dose (0.25 mg) of the dopamine agonist cabergoline in the

prevention of OHSS in women at high risk of developing OHSS in ICSI cycles. Dopamine

agonists prevent the phosphorylation of VEGF receptor 2 and reduce the in vitro and in vivo

release of vasoactive angiogenic agents. As a result, vascular permeability is also reduced.

Consequently, dopamine agonists at a daily dose of 0.5 mg have been supposed to be a

potential strategy to prevent OHSS and reduce its severity. Concerns arose about a negative

effect of cabergoline on endometrial angiogenesis, implantation, clinical and ongoing

pregnancy rates and an increased risk of congenital anomalies. We assumed that a lower

211

dose of 0.25 mg of cabergoline could safely and effectively reduce the incidence of OHSS in

women undergoing ICSI treatment without compromising pregnancy outcomes.

In this two center non blinded parallel randomised controlled trial, we included two hundred

subfertile women undergoing ICSI cycles and at risk of developing OHSS, defined as E2 on

the day of HCG > 3500 pg/ml, and ≥ 20 follicles > 12 mm,. Women with E2 > 5000 pg/ml

were excluded from the study, as their cycles were routinely cancelled out of fear for OHSS.

Women were randomly allocated - by a series of computer generated random numbers- to

cabergoline 0.25 mg /day for 8 days (n=100) from the day of HCG administration or to no

intervention (n=100). The primary outcome measure was reduction of the incidence of OHSS

per woman randomized. Secondary outcome measures included severe and mild to

moderate OHSS, early (<7–9 days) and late OHSS (>10 days), number of retrieved oocytes,

number of mature oocytes, hospitalization rate due to severe OHSS, fertilization rate, clinical

pregnancy rate, live birth rate, and incidence of congenital anomalies. Analysis was by

intention to treat.

The actual incidence of OHSS was 10% in women who were treated with cabergoline and

21% in women who were not treated. Thus, the incidence of OHSS was significantly reduced

by almost 50% (RR 0.5, 95% CI 0.29–0.83) in women treated with cabergoline. There was

no evidence of a difference in the incidence of both severe and moderate OHSS (RR 0.33,

95% CI 0.03–3.19 and 0.34, 95% CI: 0.10–1.10). There was also no evidence of a difference

in the reduction of late onset OHSS in comparison with no intervention. There was evidence

of a decrease in hemoconcentration (RR 0.44, 95% CI 0.20–0.97), ascitic fluid collection (4.6

± 1.6 vs. 6.7 ± 1.7) and ovarian volume on the day of embryo transfer (129.3 ± 70 vs. 159.8 ±

56.6) in the in women treated with cabergoline in comparison with no intervention. There was

no evidence of a difference in the hospitalization rate (RR 0.42, 95% CI: 0.06–3.14), number

of oocytes retrieved (23.4 ± 2.7 vs. 24 ± 2.6), number of MII oocytes (16.4 ± 2.8 vs. 16.8 ±

2.7), fertilization rate (72% vs. 74%). clinical pregnancy rate (42% vs. 41%); miscarriage rate

(5% vs. 5%), ongoing pregnancy rate (37% vs. 36%) and live birth rate (37% vs. 36%) in

women treated with cabergoline in comparison with no treatment. There were no fetal

congenital anomalies at all. From these data we conclude that prophylactic treatment with

cabergoline at a dose of 0.25 mg reduces the incidence of OHSS in women at high risk

undergoing IVF/ICSI treatment without compromising pregnancy outcomes.

In chapter 4 we systematically reviewed the effectiveness and safety of the dopamine

agonist cabergoline as a prophylactic treatment for the prevention of OHSS in women at high

risk and undergoing IVF/ICSI cycles. Dopamine agonists prevent the phosphorylation of

VEGF receptor 2 and reduce the in vitro and in vivo release of vasoactive angiogenic agents.

212

As a result, vascular permeability is also reduced. A number of clinical trials have tested the

clinical usefulness of dopamine agonists as a way to reduce the occurrence and severity of

OHSS. To guide women and clinicians in decision making, we designed this systematic

review and meta-analysis on the effectiveness and safety of dopamine agonist to reduce the

occurrence and severity of OHSS syndrome in high-risk patients undergoing ovarian

stimulation in IVF/ICSI cycles.

We searched MEDLINE, EMBASE, Science Direct, Cochrane Central Register of Controlled

Trials (CENTRAL) and Web of Science. National Research Register (NRR), a register of

ongoing trials, and the Medical Research Council’s Clinical Trials Register from inception

until September 2009. We retrieved 17 records after removal of duplicates, excluded 13 as

ineligible, and included four studies involving 570 randomised women. Primary outcome

measure was OHSS incidence per woman randomized. Secondary outcome measures were

live birth rate, ongoing pregnancy rate, clinical pregnancy rate and miscarriage rate.

Treatment with cabergoline reduced significantly the incidence of OHSS (OR 0.41, 95% CI

0.25-0.66; 4 RCTs, 570 women, I2= 0%), but there was no evidence of a reduction in severe

OHSS (OR 0.50, 95% CI 0.20-1.26, 4 RCTs, 570 women). There was no evidence of a

difference in live birth rate (OR 1.33, 95% CI 0.63-1.78; one RCTs, 200 women), ongoing

pregnancy rate (OR 0.88, 95% CI 0.88-0.43; one RCTs, 200 women), clinical pregnancy rate

(OR 1.07, 95% CI 0.70-1.62; 2 RCTs, 363 women, I2 =0%) and miscarriage rate (OR 0.31,

95% CI 0.03-3.07, 2 RCTs, 366 women). We conclude that prophylactic treatment with the

dopamine agonist cabergoline reduces the incidence, but not the severity of OHSS, without

compromising pregnancy rates.

In chapter 5 we present the update of a Cochrane systematic review -first published in 2010-

, that assesses the effectiveness and safety of GnRH agonists in comparison with HCG for

triggering of final oocyte maturation in IVF and ICSI for women undergoing ovarian

stimulation in a GnRH antagonist protocol in fresh autologous and donor cycles. HCG is

routinely used for final oocyte maturation triggering in IVF/ICSI cycles, but it may increase

the risk of OHSS. GnRH agonists present an alternative to HCG in stimulation regimens in

which the cycle has been down-regulated with a GnRH antagonist. Summarizing the

available evidence will help fertility experts and women to make informed decisions on final

oocyte maturation in IVF/ICSI cycles.

We searched databases including the Menstrual Disorders and Subfertility Group (MDSG)

Specialised Register of Controlled Trials, the Cochrane Central Register of Controlled Trials

(CENTRAL), MEDLINE, EMBASE, PsycINFO, the Cumulative Index to Nursing and Allied

Health Literature (CINAHL) and trial registers for published and unpublished articles from

213

inception until September 2014. We included randomised controlled trials (RCTs) comparing

gonadotropin-releasing hormone agonists versus HCG for ovulation triggering in GnRH

antagonist IVF/ICSI cycles Primary outcome measure of effectiveness was live birth rate,

primary outcome measure of safety was OHSS. Secondary outcome measures were

ongoing pregnancy rate, clinical pregnancy rate, miscarriage rate and cycle cancellation rate.

We retrieved 264 records after removal of duplicates, excluded 160 as ineligible, and

assessed 104 full-text articles. Of these, we excluded 87 and included 17 studies in the

update. We thus included seventeen randomised controlled studies, 13 in fresh autologous

cycles and four in donor-recipient cycles involving 1847 randomized women.

In women undergoing fresh autologous cycles, GnRH agonists were associated with a lower

live birth rate than was seen with HCG (OR 0.47, 95% CI 0.31 to 0.70; five RCTs, 532

women, I2 = 56%, moderate-quality evidence). This suggests that for a woman with a 31%

chance of achieving live birth with the use of HCG, the chance of a live birth with the use of a

GnRH agonist would be between 12% and 24%. In the same women, GnRH agonists were

associated with a lower incidence of mild, moderate or severe OHSS than was the case

when HCG was used (OR 0.15, 95% CI 0.05 to 0.47; eight RCTs, 989 women, I² = 42%,

moderate-quality evidence). This suggests that for a woman with a 5% risk of mild, moderate

or severe OHSS with the use of HCG, the risk of OHSS with the use of a GnRH agonist

would be between nil and 2%. The GnRH agonists were also associated with a lower

ongoing pregnancy rate than was seen with HCG (OR 0.70, 95% CI 0.54 to 0.91; 11 studies,

1198 women, I2 = 59%, low-quality evidence) and a higher miscarriage rate (OR 1.74, 95%

CI 1.10 to 2.75; 11 RCTs, 1198 women, I² = 1%, moderate-quality evidence).

In women with donor-recipient cycles, there was no evidence of a difference in live birth rate

(OR 0.92, 95% CI 0.53 to 1.61; one RCT, 212 women) or ongoing pregnancy rate (OR 0.88,

95% CI 0.58 to 1.32; three RCTs, 372 women, I² = 0%). We found a lower incidence of

OHSS in women treated with the GnRH agonist compared to women treated with HCG (OR

0.05, 95% CI 0.01 to 0.28; three RCTs, 374 women, I² = 0%) We conclude that final oocyte

maturation triggering with GnRH agonists instead of HCG in fresh autologous GnRH

antagonist IVF/ICSI cycles prevents OHSS to the detriment of the live birth rate. In donor-

recipient cycles, GnRH agonists instead of HCG resulted in a lower incidence of OHSS, with

no evidence of a difference in live birth rate. GnRH agonist as an oocyte maturation trigger

could be useful for women who choose to avoid fresh transfers for whatever reason, women

who donate oocytes to recipients or women who wish to freeze their eggs for later use in the

context of fertility preservation.

214

In chapter 6 we present the update of a Cochrane systematic review -first published in 1999,

and previously updated in 2002 and 2011- that assesses the effectiveness and safety of

volume expanders for the prevention of moderate and severe ovarian hyperstimulation

syndrome in high risk women undergoing IVF or ICSI cycles. This review provides an

evidence base for physicians and stakeholders considering the use of plasma expanders in

women at high risk of developing ovarian hyperstimulation syndrome who are undergoing

IVF/ICSI cycles.

We searched databases including the Cochrane Gynecology and Fertility Group Specialized

Register of controlled trials, the Cochrane Central Register of Controlled Trials (CENTRAL),

MEDLINE, EMBASE and trial registers from inception to September 2015. We included

RCTs comparing volume expanders versus placebo or no treatment for the prevention of

OHSS in high risk women undergoing controlled ovarian hyperstimulation as part of any

assisted reproductive technique. Primary outcome measure was the incidence of moderate

and severe OHSS. Secondary outcome measures were pregnancy rate -as confirmed by β-

HCG or pregnancy test or ultrasonic visualisation of fetal heart beat at a certain gestational

age - per woman randomized, adverse effects like allergic reaction of treatment and live birth

rate per woman randomized. We retrieved 289 records after removal of duplicates, excluded

242 as ineligible, and assessed 47 full-text articles. Of these, we excluded 37 and included

10 studies involving 1867 women comparing human albumin (seven RCTs) or hydroxyethyl

starch (two RCTs) or mannitol (one RCT) versus placebo or no treatment for the prevention

of OHSS.

There was no evidence that intra-venous albumin administration has any effect on the

incidence of severe OHSS (OR 0.71, 95% CI 0.47 to 1.07, seven RCTs, 1452 women,

I2=55%, very low quality evidence). There was some evidence that intra-venous albumin has

a beneficial effect on the incidence of moderate OHSS (OR 0.48, 95% CI 0.25 to 0.90, three

RCTs, 1113 women, I² = 41%, moderate quality evidence). This means that if the risk of

moderate OHSS with no treatment is 14.3%, it will be 4%-13% with the use of albumin. If the

risk of severe OHSS with no treatment is 16.2%, it will be 8%-17% with albumin.

Hydroxyethyl starch might reduce the incidence of severe OHSS (OR 0.13, 95% CI 0.02 to

0.75, two studies, 272 women, I2 =0%, moderate quality evidence). There was a beneficial

effect on moderate OHSS in women receiving HES compared to those receiving placebo

(OR 0.33 95% CI 0.14 to 0.75). This suggests that if the risk of moderate OHSS with no

treatment is 13.2%, it will be 2%-10% with HES. If the risk of severe OHSS with no treatment

is 3.4%, it will be 0.1-2.6%. There was also some evidence that mannitol might reduce the

incidence of severe OHSS (OR 0.40, 95% CI 0.17 to 0.91; one RCT, 226 women, moderate

quality evidence), and of moderate OHSS (OR 0.50, 95% CI 0.28 to 0.89; one RCT, 226

215

women, moderate quality evidence). This means that if the risk of moderate OHSS with no

treatment is 36.2%, it will be 13.7%-33.6% with mannitol. If the risk of severe OHSS with no

treatment is 15.5%, it will be 3%-14.3% with mannitol. There was no evidence of any effect

on pregnancy rates associated with either albumin (OR 1.21 95% CI 0.83 to 1.76, seven

RCTs, 1452 women, I2=49%, very low quality evidence) or HES (OR 0.83, 95% CI 0.34 to

2.04, one RCT, 168 women, low quality evidence), or mannitol (OR 1.17 95% CI 0.65 to

2.12; one RCT, 226 women, moderate quality evidence). Data on live birth rate were not

reported in any of the studies. Adverse events appeared to be uncommon, but were too

poorly reported to reach any firm conclusions. We conclude that intra-venous albumin

administration has no effect on the incidence of severe OHSS, but reduces the incidence of

moderate OHSS. Hydroxyethyl starch and mannitol might reduce the incidence of both

moderate and severe OHSS. There was no evidence that albumin, HES or mannitol had any

influence on pregnancy rates.

In chapter 7 we present a systematic review and meta-analysis that provides an overview of

the effectiveness of low dosing of gonadotropins in IVF cycles for women with poor ovarian

reserve. The conventional ovarian stimulation regimens for women with poor ovarian reserve

include high doses of FSH or HMG combined with various protocols of GnRH analogues to

achieve high follicular recruitment Nevertheless, despite these high doses of gonadotropins,

oocyte yield remains poor and cancellation rates are high. Mild ovarian stimulation regimens

have been suggested as alternatives for women with poor ovarian reserve, aiming at

reducing the dose of gonadotropins or shorten the duration of stimulation using oral

compounds such as antiestrogens or aromatase inhibitors, but synthesis of these data has

never been done.

We searched the PubMed, EMBASE, Web of Science, the Cochrane Library and the Clinical

Trials Registry from inception up to June 2016. We included randomized controlled trials

(RCTs) enrolling subfertile women with poor ovarian reserve and comparing ovarian

stimulation regimens with low doses of gonadotropins including co-treatment with oral

compounds such as clomiphene citrate and letrozole, irrespective of the GnRH analogues

protocol applied, undergoing IVF/ICSI treatment versus ovarian stimulation regimens with

high doses of gonadotropins. We considered any comparison between two different doses of

gonadotropins and combinations of gonadotropins with oral compounds to shorten the

duration of stimulation and thereby lowering the total dose of gonadotropins suitable for

inclusion in our review. We defined low doses as the range between 150-300 IU per day and

high doses as the range between 450-600 IU per day. Primary outcome measure was

ongoing pregnancy. Secondary outcome measures were clinical pregnancy rate, live birth

rate, duration of gonadotropins stimulation, total dose of gonadotropins, number of cumulus–

216

oocytes complexes (COCs) retrieved, number of metaphase II (MII) oocytes, number of

embryos obtained, number of embryos transferred, endometrial thickness on the day of hCG

and cycle cancellation rate due to poor response. We retrieved 788 records; we screened the

titles of these manuscripts and considered 36 studies to be potentially eligible for inclusion in

the review. We excluded 21 studies; 14 studies after reading the abstracts and four studies

since they were ongoing. We thus included 15 studies involving 2183 women.

Six studies compared low doses of gonadotropins versus high doses of gonadotropins.

There was no evidence of a difference in ongoing pregnancy rate (RR 1.05, 95% CI 0.70 to

1.56; 4 RCTs, I2 = 0%, moderate quality evidence), clinical pregnancy rates (RR 1.05, 95%

CI 0.70 to 1.56; 4 RCTs, I2= 0 moderate quality evidence), and live birth rates (RR 0.85, 95%

CI 0.37 to 1.94; 2 RCTs, I2 = 0%, moderate quality evidence). This suggests that for a

woman with a 13% chance of achieving an ongoing pregnancy with the use of high doses of

gonadotropins, the chance of an ongoing pregnancy with the use of low doses of

gonadotropins would be between 7 % and 17 %. The total dose of gonadotropins required for

ovarian stimulation was significantly decreased in women who were treated with low doses of

gonadotropins compared with those who were treated with high doses of gonadotropins

(WMD -2222 IU, 95% CI -2985 to- 1459; 3 RCTs, I2 = 99%). There was no evidence of a

difference in the duration required to complete ovarian stimulation (WMD -1.3 days, 95% CI -

1.23 to 0.61; 3 RCTs, 1024 women, I2 = 88%). There was evidence of a difference in the

number of retrieved oocytes (COCs) in favour of high doses of gonadotropins (WMD - 1.02

COCs, 95% CI -1.83 to -0.22; 3 RCTs, I2 = 96%).

Nine studies compared ovarian stimulation using gonadotropins combined with the oral

compounds letrozole, (n=6) or clomiphene citrate (CC) (n=3) versus high doses of

gonadotropins. There was no evidence of a difference in ongoing pregnancy rate (RR: 0.90,

95% CI: 0.63 to 1.27; 3 RCTs, I2 =0%) and clinical pregnancy rates (RR 1.00, 95% CI 0.78 to

1.28; 8 RCTs, I2 =0%, moderate quality evidence). This suggests that for a woman with a

13% chance of achieving ongoing pregnancy with the use of gonadotropins, the chance of an

ongoing pregnancy with the use of gonadotropins combined with oral compounds would be

between 7 % and 16 %. The total dose of gonadotropins required for ovarian stimulation was

significantly decreased in women who were treated with gonadotropins combined with oral

compounds when compared with those who were treated with gonadotropins only(WMD: -

2027 IUs, 95% CI -2583 to- 1470: 9 RCTs, I2= 98%). Significantly fewer days were required

to complete ovarian stimulation in the women who were treated with gonadotropins

combined with oral compounds when compared with those who were treated with

gonadotropins only(WMD - 1.79 days, 95% CI - 2.75 to – 0, 84; 7 RCTs, I2= 92%). There was

no evidence of a difference in the number of retrieved oocytes between the women who were

treated with gonadotropins combined with oral compounds and those who were treated with

217

gonadotropins only (WMD - 0.5 COCs, 95% CI - 1.41 to 0.36; 9 RCTs I2= 91%). We conclude

that low dosages of gonadotropins or gonadotropins combined with oral compounds could be

an alternative treatment option in women with poor ovarian reserve undergoing IVF.

In chapter 8 we give the results of an open-label multicenter randomized trial , designed to

compare one cycle of a mild ovarian stimulation strategy consisting of low-dose

gonadotropins (150 IU FSH) and pituitary down regulation with a GnRH-antagonist to one

cycle of a conventional ovarian stimulation strategy consisting of high-dose gonadotropins

(450 IU HMG) and pituitary down regulation with a long mid-luteal GnRH-agonist in 394

women of advanced maternal age and/or women with poor ovarian reserve undergoing IVF

between May 2011 and April 2014. Primary outcome measure was ongoing pregnancy rate.

Secondary outcome measures were clinical pregnancy, biochemical pregnancy, multiple

pregnancy, early pregnancy loss, number of oocytes retrieved, number of metaphase II

oocytes, fertilization rate, number of embryos obtained, number of embryo transfers, total

FSH/HMG doses used for ovarian stimulation, cancellation rate, and drop-out rate. With a

predefined non-inferiority margin of 10%, meaning that the upper boundary of the 95%

confidence interval of the absolute difference between the primary endpoint in the two study

groups would be lower than 10%. We determined the sample size on the basis of an

expected ongoing pregnancy rate in the conventional strategy group of 20%. On basis of the

chi-square statistic and calculating with 80% power to detect the predefined non-inferiority

margin at a one sided α level of 0.05; we would need 177 women in each study group.

Assuming a loss to follow-up of 10%, the total study population was set at 394 people (197

per arm).

We randomly assigned 195 women to the mild ovarian stimulation strategy and 199 women

to the conventional ovarian stimulation strategy. Analyses were on an intention-to-treat basis.

Ongoing pregnancy rate was 12.8% (25/195) versus 13.5% (27 /199) leading to a RR of 0.91

(95% CI 0.50-1.64).We found no evidence of any differences in rates of clinical pregnancy,

early pregnancy loss, twin pregnancies and conception. One ectopic pregnancy occurred in

each intervention arm. The duration of ovarian stimulation was significantly lower in the mild

ovarian stimulation strategy (8.42 ± 2.89) compared with the conventional ovarian stimulation

strategy (9.67 ± 3.10) with a mean difference of minus 1.2 days (95% CI -1.88 to - 0.62).

Significantly lower amount of gonadotropins was used in the mild ovarian simulation strategy,

with a mean difference of minus 3135 IU (95% CI:-3331 to -2940). On the day of hCG, the

number of follicles ≥ 15 mm was significantly lower in the mild ovarian stimulation strategy

versus the conventional ovarian simulation strategy with a mean difference of minus 1.2

follicles (95% CI -1.88 to - 0.55). In the mild ovarian stimulation strategy 52 (26%) cycles

218

were cancelled and 37 (18%) cycles in the conventional ovarian stimulation strategy (RR 1.5;

95% CI 0.96 - 2.5). The mild ovarian stimulation strategy resulted in significantly fewer

oocytes (3.3 ± 2.0 vs. 5.0 ± 4.0) and fewer mature oocytes (MII) (2.7± 2.0 vs. 4.0 ±3.0,)

obtained. There were less fertilized oocytes (2.4 ± 2.0 vs. 3.4 ± 3.0), and embryos (2.0 ± 1.9

vs. 2.7 ± 2.4) but the number of top quality embryos.

(0.8 ± 1.1 vs. 0.8 ± 1.2) and embryos transferred (0.8 ± 1.3 vs. 0.8 ± 1.2) were similar. The

strength of this study lies in the comparison between two strategies of ovarian stimulation in

women with poor ovarian reserve in a well powered and large multicenter international RCT

with central randomization comparing, the lowest dose of FSH ever used in a GnRH

antagonist protocol, with conventional ovarian stimulation with high dosages of 450 IU of

HMG. In addition, the dose of the gonadotropins was not increased or decreased throughout

the stimulation phase. A limitation of our study was the lack of data concerning the

cryopreservation of surplus embryos, so we are not informed on cumulative pregnancy rates.

However, the number of top quality embryos and embryos transferred were similar, so, by

extrapolation, the number of frozen embryos was probably evenly distributed among the two

strategies and in view of the poor ovarian response, few in number. Another limitation is that

we were not able to follow up on the ongoing pregnancies in all centers, so we are not

informed on live birth rates.

We conclude that mild ovarian stimulation strategy is non-inferior to conventional ovarian

stimulation in terms of the pregnancy outcomes. Thus, mild ovarian stimulation should be the

treatment of choice in women with poor reserve undergoing IVF treatment.

Implications for clinical practice

Women at risk for OHSS can be treated with a GnRH antagonist protocol which in itself will

result in a more mitigated response compared with a long GnRH agonist protocol. In case

there is still a risk of OHSS, a GnRH agonist trigger can then be administrated with

cryopreservation of all embryos. However, despite this treatment regimen severe OHSS has

occasionally been reported. So caution is needed when using this approach. In this respect,

it might be of value to identify high responders before start of the stimulation and adjust the

FSH dose.

Also, we have demonstrated that the use of the dopamine agonist cabergoline reduces

OHSS by 50%; but it is not commonly used nowadays because it is only useful in the

prevention of mild and early OHSS, and not of severe or late OHSS. Currently, we do not

recommend the use of a dopamine agonist. Administration of intra-venous albumin does not

reduce the risk of severe OHSS and should not be recommended for the routine prevention

219

of OHSS. Hydroxyethyl starch and mannitol might reduce the incidence of moderate and

severe OHSS. They are cheaper and are non-biologically derived colloid fluids that are free

from the risks associated with albumin. Thus, we recommend their use instead of human

albumin to reduce the severity of OHSS.

We have shown that women with poor ovarian reserve may benefit from treatment with low

dose of gonadotropins- ≈ 150 IU of gonadotropins- or with oral compounds – clomiphene

citrate or letrozole- with or without dose adjustment. Mild ovarian stimulation should be the

intervention of choice instead of conventional ovarian stimulation with high doses of

gonadotropins. This may lead to considerable cost savings.

Implications for future research

It may be more valuable to focus on the individualisation of ovarian stimulation and to modify

IVF treatment protocols to improve outcomes in terms of increased live birth rates and

decreased incidence of OHSS, multiple pregnancies, patient burden and costs. A direct

benefit of treatment individualization in terms of increased pregnancy rates and cost-

effectiveness remains to be established. Future studies focusing on treatment

individualization and cost-effectiveness for the prevention of high response and reducing the

cost of treatment in women with poor ovarian reserve may shed some light on this issue.

Thus, well powered studies are needed to assess the strategy of mild ovarian stimulation, in

poor and high responders with different drugs, doses of gonadotropins and various GnRH

analogues to achieve a proper balance between IVF success, burden of treatment,

complications and cost.

The question is whether couples will participate in such trials or whether they will seek

conventional treatment in commercial clinics, if randomised to mild ovarian stimulation. Thus,

understanding the considerations of women in expressing their preferences regarding mild

ovarian stimulation might contribute to improvement in counselling and shared decision-

making. So, patient preference studies in the form of discrete choice experiments to

investigate women’s perspectives on mild stimulation with low dose of gonadotropins with or

without oral compounds with respect to live birth rate and costs should be undertaken in both

women with poor and high ovarian reserve. The same is true for the GnRH agonist trigger in

antagonist cycles followed by cryopreservation of all embryos. Studies are needed to

evaluate patients’ preferences for GnRH agonist trigger in the light of the low pregnancy rate

and the need for embryo cryopreservation.

The studies reported in this thesis which evaluated various preventive strategies of OHSS,

did not reveal the best possible outcomes. Administration of albumin as volume expanders

220

had no substantial effect in preventing severe OHSS in subfertile women undergoing ovarian

stimulation and IVF treatment. Further evaluation of the use of albumin for the prevention of

OHSS is therefore not advocated. The few studies evaluating Hydroxyethyl starch and

mannitol have shown a substantial effect in the reduction of moderate to severe OHSS.

Thus, further research is needed to reveal whether these intra-venous fluids can fulfill their

promise.

Also, comprehensive network meta-analysis is needed to compare the prophylactic

effectiveness of most of the popular published regimens on OHSS and to estimate the

influence of these treatments on pregnancy rates after ART. Other interventions such as

intravenous calcium infusion need more studies to assess its cost-effectiveness and safety.

Finally, the exact underlying pathophysiology of OHSS is unclear. Thus, more studies are

required to elucidate the pathophysiology behind the condition.

221

References

• Boivin J, Bunting L, Collins JA, Nygren KG. International estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical care. Hum Reprod. 2007; 22(6):1506-12.


• Baumgarten M, Polanski L, Campbell B, Raine-Fenning N. Do dopamine agonists prevent or reduce the severity of ovarian hyperstimulation syndrome in women undergoing assisted reproduction? A systematic review and meta-analysis. Hum Fertil 2013; 16(3):168-74.



• D'Angelo A, Brown J, Amso NN. Coasting (withholding gonadotrophins) for preventing ovarian hyperstimulation syndrome. Cochrane Database Syst Rev. 2011 15;(6):CD002811.

• de Boer EJ, Den Tonkelaar I, Burger CW, Looman CW, van Leeuwen FE, te Velde ER; The number of retrieved oocytes does not decrease during consecutive gonadotrophin-stimulated IVF cycles. OMEGA project group. Hum Reprod. 2004;19(4):899-904.




• Heijnen EM, Eijkemans MJ, De Klerk C, Polinder S, Beckers NG, Klinkert ER, Broekmans FJ, Passchier J, Te Velde ER, Macklon NS, Fauser BC. A mild treatment strategy for in-vitro fertilisation: a randomised non-inferiority trial. Lancet 2007; 369 (9563): 743–749.


222

• Onofriescu A, Bors A, Luca A, Holicov M, Onofriescu M, Vulpoi C GnRH Antagonist IVF Protocol in PCOS. Curr Health Sci J. 2013;39(1):20-5.






223

Chapter 10

Samenvatting

224

Subfertiliteit wordt gedefinieerd als onvervulde kinderwens na tenminste een jaar van

regelmatige onbeschermde coitus (Zegers-Hochschild et al., 2009). Het komt voor bij

ongeveer 10% van alle paren in de vruchtbare leeftijd (Boivin et al., 2007). De introductie van

medisch geassisteerde voortplantingstechnieken heeft miljoenen paren hoop geboden. Deze

technieken bestaan uit ovulatie inductie, intra-uteriene inseminatie (IUI) met of zonder

ovariële stimulatie, en in vitro fertilisatie (IVF) met of zonder geassisteerde fertilisatie (ICSI).

Bij IVF is ovariële stimulatie met gonadotrophines een integraal onderdeel van de

behandeling. Het is geïntroduceerd om het aantal embryo’s te verhogen om te compenseren

voor slechte embryo kwaliteit, maar wordt nu gebruikt om selectie van het beste embryo voor

verse transfer en de cryopreservatie van overtollige embryo’s mogelijk te maken (Fauser et

al., 2005). Stimulatie protocollen met hoge doses exogene gonadotrophines, gecombineerd

met gonadotropin releasing hormone (GnRH) analogen voor de preventie van premature LH

pieken worden het vaakst gebruikt (Macklon et al., 2006).

De eicelopbrengst na deze protocollen hangt af van de follikel voorraad. Bij vrouwen met een

normale of verhoogde ovariële reserve, kunnen hoge doses leiden tot een excessieve

ovariële reactie met het ovarieel hyperstimulatie syndroom (OHSS) als gevolg.

Omdat de behandeling van OHSS bestaat uit het verlichten van de symptomen terwijl de

onderliggende conditie langzaam verbetert, is preventie van deze complicatie bij vrouwen die

een risico lopen op het krijgen van OHSS het meest aangewezen. Er zijn verschillende

manieren om het risico op OHSS te verminderen. Primaire preventie bestaat uit

geïndividualiseerde ovariële stimulatie protocollen met milde doses gonadotrophines

(Heijnen et al., 2007; Rinaldi et al., 2014), gebruik van GnRH antagonisten (Onofriescu et al.,

2013) en in vitro maturatie (Yu et al., 2012). Secundaire preventie behelst alle strategieën die

erop gericht zijn een excessieve ovariële respons tegen te gaan, d.w.z. afbreken van de

cyclus (Rizk & Aboulghar 1991), coasting (D'Angelo et al.,2011), ovulatie inductie met lage

doses HCG (Tiboni et al.,2016) of met een GnRH agonist (Casper RF 2015), toediening van

een dopamine agonist ten tijde van de follikel aspiratie (Baumgarten et al., 2013);

intraveneuze volume expanders ten tijde van de follicel aspiratie (Gokmen et al., 2001) en

cryopreservatie van eicellen of embryo’s (Boothroyd et al., 2015).

Bij vrouwen met een slechte reactie op ovariële stimulatie, zoals oudere vrouwen is er een

fysiologische vermindering van de ovariële reserve van primordiale follikels (de Boer et al.,

2004). Bij jonge vrouwen weerspiegelt een slechte reactie op ovariële stimulatie een

pathologische vermindering van het aantal en de kwaliteit van primordiale follikels. Heden

ten dage bestaat het conventionele ovariële stimulatie schema voor vrouwen met een

slechte ovariële reserve uit hoge doses FSH of HMG gecombineerd met verschillende

225

protocollen GnRH analogen om zoveel mogelijk follikels tot ontwikkeling proberen te krijgen

(Bosdou et al., 2012). Desalniettemin blijft de eicelopbrengst, ondanks deze hoge dosering

gonadotrophines, slecht en is het aantal cycli dat wordt afgebroken hoog (Dercourt et al.,

2016).

In dit proefschrift beschrijven wij een aantal systematische reviews en meta-analyses om de

meest gebruikte pharmacologische interventies voor de preventie van OHSS te evalueren,

zoals het gebruik van GnRH antagonisten, dopamine agonist supplementatie, GnRH agonist

trigger voor de laatste fase van de eicel rijping en toediening van intraveneus vocht. Wij

beschrijven ook een gerandomiseerde trial die de laagst mogelijke dosering cabergoline

evalueert bij tweehonderd vrouwen die een risico liepen om OHSS te ontwikkelen.

Aan het andere eind van het spectrum van ovariële respons ontwierpen we een

gerandomiseerde klinische trial uitgevoerd in meerdere centra om het eventuele positieve

effect te evalueren van milde ovariële stimulatie bij vrouwen met een slechte ovariële reserve

die IVF ondergingen. Deze vrouwen waren ouder dan 35 jaar, hadden een verhoogde

uitgangswaarde van FSH level > 10 IU/ml ongeacht leeftijd, een laag aantal antrale follikels

van minder dan 5 follikels of een slechte ovariële respons of afbreking van de cyclus tijdens

een eerdere IVF cyclus ongeacht leeftijd. Tenslotte hebben we op systematische wijze

gerandomiseerde klinische trials samengevat, die lage doses gonadotrophines bij ovariële

stimulatie vergeleken met hoge doses gonadotrophines in termen van doorgaande

zwangerschap per verse IVF poging bij vrouwen met slechte ovariële reserve. .In hoofdstuk 1 presenteren we een algemene inleiding en beschrijven we de doelstellingen van het

proefschrift.

In hoofdstuk 2 geven we de update van een Cochrane review –voor de eerste keer

gepubliceerd in 2001, en eerder bijgewerkt in 2006 en 2011- dat de effectiviteit en veiligheid

beoordeelt van downregulatie van de hypofyse door GnRH antagonisten vergeleken met het

standaard lange protocol van GnRH agonisten als onderdeel van ovariële stimulatie

schema’s bij IVF/ICSI cycli. GnRH antagonisten voorkomen een luteinizerend hormoon (LH)

piek gedurende stimulatie zonder de hypo-oestrogene bijeffecten, het flare-up fenomeen, of

de lange periode van down-regulatie geassocieerd met GnRH agonisten. De antagonisten

remmen direct en snel de afgifte van gonadotrophines binnen enkele uren via competitieve

binding aan GnRH receptoren in de hypofyse. Deze eigenschap maakt het mogelijk dat zij

gebruikt kunnen worden op elk moment van de folliculaire fase. Vrouwen die antagonisten

hebben gebruikt hebben een lagere incidentie van OHSS. Uitgaande van gelijke klinische

uitkomsten voor de antagonist en agonist protocollen, zouden deze voordelen een wijziging

van het standaard lange agonisten protocol naar antagonisten regimes rechtvaardigen.

226

Dus doorzochten wij de Medline, EMBASE, Cochrane database, Psyc INFO, CINHAL, Trial

registers, DARE, LILACS database en OpenGrey, vanaf oprichting tot april 2015. Wij

includeerden gerandomiseerde klinische trials die GnRH antagonisten protocollen

vergeleken met lange GnRH agonisten protocollen bij vrouwen die in vitro fertilisatie (IVF) of

intracytoplasmic sperm injectie (ICSI) ondergingen. Primaire uitkomstmaat van effectiviteit

was geboorte van een levend kind en primaire uitkomstmaat van veiligheid was OHSS.

Secundaire uitkomstmaten waren doorgaande zwangerschap, klinische zwangerschap,

miskramen en afbreken van de cyclus. Wij vonden 479 artikelen na verwijderen van dubbel

publicaties, excludeerden 399 artikelen omdat zij niet in aanmerking kwamen en

beoordeelden 80 artikelen. Van deze 80 excludeerden we 51 en includeerden we 28 (29

artikelen) studies in de update en voegden deze toe aan de 45 studies van de review uit

2011. We includeerden dus 73 gerandomiseerde klinische studies, met in totaal 12,212

gerandomiseerde vrouwen.

Er was geen bewijs van een verschil in het aantal geboortes van een levend kind tussen

GnRH antagonisten en agonisten (OR 1.02, 95% BI 0.85 tot 1.23; 12 RCT’s , 2303 vrouwen,

I2 = 27%, matige kwaliteit bewijs). Dit betekent dat als de kans op de geboorte van een

levend kind na een GnRH agonist 29% is, de kans na een GnRH antagonist tussen de 25%

en 33% zou zijn. GnRH antagonisten waren geassocieerd met een lagere incidentie van

OHSS dan GnRH agonisten (OR 0.61, 95% BI 0.51 tot 0.72; 36 RCT’s , 7944 vrouwen, I2 =

31%, matige kwaliteit bewijs). Dit betekent dat als het risico op OHSS na een GnRH agonist

11% is, het risico na een GnRH antagonist tussen de 6% en 9% zou zijn. Er was geen bewijs

van een verschil in miskramen per vrouw gerandomiseerd tussen GnRH antagonisten en

agonisten (OR 1.03, 95% BI 0.82 tot 1.29; 34 RCT’s , 7082 vrouwen, I2 = 0%, matige

kwaliteit bewijs). Met betrekking tot het afbreken van de cyclus, waren GnRH antagonisten

geassocieerd met een lagere incidentie van het afbreken van de cyclus om OHSS te

voorkomen (OR 0.47, 95% BI 0.32 tot 0.69; 19 RCT’s , 4256 vrouwen, I2 = 0%). Afbreken van

de cyclus als gevolg van slechte ovariële respons was hoger bij vrouwen die behandeld

werden met GnRH antagonisten dan degenen die behandeld waren met GnRH agonisten

(OR 1.32, 95% BI 1.06 tot 1.65; 25 RCT’s , 5230 vrouwen, I2 = 68%; matige kwaliteit bewijs).

We concluderen dat het gebruik van GnRH antagonisten vergeleken met lange GnRH

agonist protocollen is geassocieerd met een substantiële vermindering in OHSS zonder de

kans op de geboorte van een levend kind te verminderen.

In hoofdstuk 3 geven we de resultaten weer van een gerandomiseerde klinische trial die de

effectiviteit en veiligheid onderzocht van een lage dosis (0.25 mg) van de dopamine agonist

Cabergoline bij de preventie van OHSS bij vrouwen met een hoog risico op het ontwikkelen

van OHSS in ICSI cycli. Dopamine agonisten voorkomen de phosphorylatie van VEGF

227

receptor 2 en verminderen de in vitro en in vivo afgifte van vasoactieve angiogenetische

stoffen. Als een gevolg hiervan is de vasculaire permeabiliteit ook verminderd. Dit heeft tot

het idee geleid dat dopamine agonisten bij een dagelijkse dosering van 0.5 mg een

potentiele strategie is om OHSS te voorkomen en de ernst te verminderen. Er waren wel

zorgen over een eventueel negatief effect van cabergoline op l angiogenese in het

endometrium, implantatie, klinische en doorgaande zwangerschappen en een toegenomen

risico op congenitale anomalieën. We namen aan dat een lagere dosis van 0.25 mg

cabergoline veilig en effectief de incidentie van OHSS zou kunnen terugdringen bij vrouwen

die een ICSI behandeling ondergingen zonder de zwangerschapsuitkomsten negatief te

beïnvloeden.

In deze twee center niet geblindeerde parallel gerandomiseerde klinische trial, includeerden

wij 200 subfertiele vrouwen die ICSI cycli ondergingen en at risk waren op het ontwikkelen

van OHSS, gedefinieerd als E2 op de dag van HCG > 3500 pg/ml, en ≥ 20 follikels > 12 mm.

Vrouwen met E2 > 5000 pg/ml werden geëxcludeerd van de studie, omdat hun cycli

routinematig werden afgebroken uit angst voor OHSS. Vrouwen werden willekeurig

toegewezen – door een serie willekeurige nummers gegenereerd door een computer- aan

cabergoline 0.25 mg /dag voor 8 dagen (n=100) van de dag van HCG toediening of aan geen

interventie (n=100). De primaire uitkomstmaat was afname van de incidentie van OHSS per

gerandomiseerde vrouw. Secundaire uitkomstmaten waren ernstige en milde tot matige

OHSS, vroege (<7–9 dagen) en late OHSS (>10 dagen), aantal verkregen oocyten, aantal

mature oocyten, hospitalisatie ten gevolge van ernstige OHSS, fertilisatie graad, klinische

zwangerschap, geboorte van een levend kind, en incidentie van congenitale anomalieën. De

analyse was een intention to treat analyse.

De actuele incidentie van OHSS was 10% bij vrouwen die waren behandeld met cabergoline

en 21% bij vrouwen die niet waren behandeld. Dus was de incidentie van OHSS significant

verminderd met bijna 50% (RR 0.5, 95% BI 0.29–0.83) bij vrouwen behandeld met

cabergoline. Er was geen bewijs van een verschil in de incidentie van zowel ernstige als

matig ernstige OHSS (RR 0.33, 95% BI 0.03–3.19 en 0.34, 95% BI: 0.10–1.10). Er was ook

geen bewijs van een verschil in vermindering van late OHSS in vergelijking met geen

interventie. Er was bewijs van een vermindering in hemoconcentratie (RR 0.44, 95% BI

0.20–0.97), ascites (4.6 ± 1.6 vs. 6.7 ± 1.7) en ovarieel volume op de dag van embryo

transfer (129.3 ± 70 vs. 159.8 ±56.6 ) bij de vrouwen behandeld met cabergoline in

vergelijking met geen interventie. Er was geen bewijs voor een verschil in hospitalisatie

graad (RR 0.42, 95% BI: 0.06–3.14), aantal verkregen oocyten (23.4 ± 2.7 vs. 24 ± 2.6),

aantal MII oocytes (16.4 ± 2.8 vs. 16.8 ± 2.7), fertilisatie graad (72% vs. 74%). klinische

zwangerschap (42% vs. 41%); miskramen (5% vs. 5%), doorgaande zwangerschap (37% vs.

228

36%) en geboorte van een levend kind (37% vs. 36%) bij vrouwen behandeld met

cabergoline in vergelijking met geen behandeling. Er waren geen congenitale afwijkingen. Uit

deze gegevens concluderen we dat prophylactische behandeling met cabergoline bij een

dosering van 0.25 mg de incidentie van OHSS bij vrouwen met een verhoogd risico en die

een IVF/ICSI behandeling ondergingen vermindert, zonder de zwangerschapsuitkomsten

nadelig te beïnvloeden.

In hoofdstuk 4 we presenteren we een systematisch overzicht van de literatuur over de

effectiviteit en veiligheid van de dopamine agonist cabergoline als prophylactische

behandeling van OHSS bij vrouwen die een hoog risico hebben op het krijgen van OHSS als

gevolg van een IVF/ICSI behandeling. Dopamine agonisten voorkomen de phosphorylatie

van VEGF receptor 2 en verminderen de in vitro en in vivo afgifte van vasoactieve

angiogenetische stoffen. Als een gevolg hiervan is de vasculaire permeabiliteit ook

verminderd. Een aantal klinische trials hebben het gebruik van dopamine agonisten

onderzocht als een manier om de kans op OHSS en de ernst ervan te verminderen. Om

vrouwen en clinici te helpen bij hun besluitvorming, hebben we deze systematische review

en meta-analyse uitgevoerd over de effectiviteit en veiligheid van dopamine agonisten bij het

verminderen van de kans op OHSS en de ernst ervan bij hoog risico patiënten die ovariële

stimulatie ondergingen tijdens IVF/ICSI cycli.

We doorzochten MEDLINE, EMBASE, Science Direct, Cochrane Central Register of

Controlled Trials (CENTRAL) en Web of Science. National Research Register (NRR),

register van lopende trials, en de Medical Research Council’s Clinical Trials Register vanaf

oprichting tot september 2009. Wij vonden 17 artikelen na verwijderen van dubbel

publicaties, excludeerden 13 artikelen omdat zij niet in aanmerking kwamen, en

beoordeelden 4 artikelen. Primaire uitkomstmaat was OHSS incidentie per gerandomiseerde

vrouw. Secondaire uitkomstmaten waren geboorte van een levend kind, doorgaande

zwangerschap, klinische zwangerschap en miskramen.

Behandeling met cabergoline verminderde significant de incidentie van OHSS (OR 0.41,

95% BI 0.25-0.66; 4 RCT’s, 570 vrouwen, I2= 0%), maar er was geen bewijsbewijs van een

vermindering van ernstige OHSS (OR 0.50, 95% BI 0.20-1.26, 4 RCT’s, 570 vrouwen). Er

was geen bewijs van een verschil in geboorte van een levend kind (OR 1.33, 95% BI 0.63-

1.78; een RCT, 200 vrouwen), doorgaande zwangerschap (OR 0.88, 95% BI 0.88-0.43; een

RCT, 200 vrouwen), klinische zwangerschap (OR 1.07, 95% BI0.70-1.62; 2 RCT’s , 363

vrouwen, I2 =0%) en miskramen (OR 0.31, 95% BI 0.03-3.07, 2 RCT’s , 366 vrouwen). We

concluderen dat prophylactische behandeling met de dopamine agonist cabergoline de

229

incidentie, maar niet de ernst van OHSS vermindert, zonder de zwangerschapsuitkomsten

nadelig te beïnvloeden.

In hoofdstuk 5 presenteren wij de update van een Cochrane systematische review –voor

het eerst gepubliceerd in 2010-, dat de effectiviteit en veiligheid beoordeelt van GnRH

agonisten in vergelijking met HCG ter verkrijging van de uiteindelijke eicel uitrijping tijdens

IVF/ICSI bij vrouwen die ovariële stimulatie ondergingen in een GnRH antagonist protocol bij

verse autologe en donor cycli. HCG wordt routinematig gebruikt ter verkrijging van de

uiteindelijke eicel uitrijping tijdens IVF/ICSI cycli, maar kan het risico op OHSS verhogen.

GnRH agonisten vormen een alternatief voor HCG in stimulatie regimes waarin de cyclus is

down-gereguleerd met een GnRH antagonist. Deze samenvatting kan gynaecologen en

vrouwen helpen om geïnformeerde beslissingen te nemen bij de uiteindelijke eicel uitrijping

in IVF/ICSI cycli.

Wij doorzochten de databases van de Menstrual Disorders and Subfertility Group (MDSG)

Specialised Register of Controlled Trials, de Cochrane Central Register of Controlled Trials

(CENTRAL), MEDLINE, EMBASE, PsycINFO, de Cumulative Index to Nursing en Allied

Health Literature (CINAHL) en de trial registers voor gepubliceerde en ongepubliceerde

artikelen vanaf de oprichting tot september 2014. We includeerden gerandomiseerde

klinische trials (RCT’s ) die gonadotropin-releasing hormoon agonisten met HCG voor

ovulatie inductie vergeleken in IVF/ICSI cycli down-gereguleerd met GnRH antagonisten.

Primaire uitkomstmaat van effectiviteit was de geboorte van een levend kind, en de primaire

uitkomstmaat van veiligheid was OHSS. Secundaire uitkomstmaten waren doorgaande

zwangerschap, klinische zwangerschap, miskramen en afbreken van de cyclus. Wij vonden

264 artikelen na verwijderen van dubbel publicaties, excludeerden 160 artikelen omdat zij

niet in aanmerking kwamen, en beoordeelden uiteindelijk 104 artikelen. Van dezen,

excludeerden we 87 studies en includeerden 17 studies in de update. We includeerden dus

17 gerandomiseerde klinische trials, 13 in verse autologe cycli en 4 in donor cycli met in het

totaal 1847 gerandomiseerde vrouwen.

Bij vrouwen die verse autologe cycli ondergingen, waren GnRH agonisten geassocieerd met

minder geboortes van een levend kind dan met HCG (OR 0.47, 95% BI 0.31 tot 0.70; 5

RCT’s , 532 vrouwen, I2 = 56%, matige kwaliteit bewijs). Dit betekent dat voor een vrouw met

een 31% kans op een levend geboren kind met het gebruik van HCG, de kans op een levend

geboren kind met het gebruik van een GnRH agonist tussen 12% en 24% zou zijn. Bij

dezelfde vrouwen waren GnRH agonisten geassocieerd met een lagere incidentie van milde,

matige of ernstige OHSS dan wanneer HCG was gebruikt (OR 0.15, 95% BI 0.05 tot 0.47; 8

RCT’s , 989 vrouwen, I² = 42%, matige kwaliteit bewijs). Dit betekent dat voor een vrouw met

230

een 5% risico op milde, matige of ernstige OHSS met het gebruik van HCG, het risico op

OHSS met gebruik van een GnRH agonist tussen de nul en 2% zou zijn. De GnRH

agonisten waren ook geassocieerd met minder doorgaande zwangerschappen dan met HCG

(OR 0.70, 95% BI 0.54 tot 0.91; 11 studies, 1198 vrouwen, I2 = 59%, lage kwaliteit bewijs) en

meer miskramen (OR 1.74, 95% BI 1.10 tot 2.75; 11 RCT’s , 1198 vrouwen, I² = 1%, matige

kwaliteit bewijs).

Bij vrouwen met donor cycli was er geen bewijs voor een verschil in levend geboren kinderen

(OR 0.92, 95% BI 0.53 tot 1.61; 1 RCT, 212 vrouwen) of doorgaande zwangerschappen (OR

0.88, 95% BI 0.58 tot 1.32; 3 RCT’s , 372 vrouwen, I² = 0%). We vonden een lagere

incidentie van OHSS in vrouwen behandeld met een GnRH agonist vergeleken met vrouwen

behandeld met HCG (OR 0.05, 95% BI 0.01 tot 0.28; 3 RCT’s , 374 vrouwen, I² = 0%) We

concluderen dat uiteindelijke eicel uitrijping met GnRH agonisten in plaats van met HCG in

verse autologe GnRH antagonist IVF/ICSI cycli OHSS voorkomt ten nadele van het aantal

levend geboren kinderen. In donor cycli leidde GnRH agonisten in plaats van HCG tot een

lagere incidentie van OHSS, zonder bewijs voor een verschil in levend geboren kinderen.

GnRH agonisten als ovulatie trigger zouden nuttig kunnen zijn voor vrouwen die geen verse

embryo transfer willen om welke reden dan ook, vrouwen die oocyten doneren of vrouwen

die hun eicellen willen invriezen voor later gebruik in de context van fertiliteits preservatie.

In hoofdstuk 6 presenteren we de update van een Cochrane systematische review –voor

het eerst gepubliceerd in 1999, en eerder herzien in 2002 en 2011- dat de effectiviteit en

veiligheid beoordeelt van volume expanders voor de preventie van matige en ernstige OHSS

bij hoog risico vrouwen die IVF of ICSI ondergingen. Deze review verschaft de gegevens

voor dokters en stakeholders die het gebruik van plasma expanders overwegen bij vrouwen

die een hoog risico hebben op het ontwikkelen van OHSS in het kader van IVF/ICSI.

We doorzochten de databases van de Cochrane Gynecology and Fertility Group Specialized

Register of controlled trials, de Cochrane Central Register of Controlled Trials (CENTRAL),

MEDLINE, EMBASE en de trial registers vanaf hun oprichting tot september 2015. We

includeerden RCT’s die volume expanders vergelijken met placebo or geen behandeling

voor de preventie van OHSS in hoog risico vrouwen die ovariële hyperstimulatie ondergingen

als onderdeel van een geassisteerde voortplantingstechniek. Primaire uitkomstmaat was de

incidentie van matige en ernstige OHSS. Secundaire uitkomstmaten waren zwangerschap

bevestigd met β-HCG of een zwangerschapstest of echoscopische visualisatie van foetale

hart activiteit bij een bepaalde zwangerschapsduur per gerandomiseerde vrouw,

bijwerkingen als allergische reacties en de geboorte van een levend kind per

gerandomiseerde vrouw. Wij vonden 289 artikelen na verwijderen van dubbel publicaties,

231

excludeerden 242 artikelen omdat zij niet in aanmerking kwamen, en beoordeelden

uiteindelijk 47 artikelen. Van dezen excludeerden we er 37 en includeerden 10 studies met in

totaal 1867 vrouwen die humaan albumine (7 RCT’s ) of hydroxyethyl starch (2 RCT’s ) of

mannitol (1 RCT) vergeleken met placebo of geen behandeling voor de preventie van OHSS.

Er was geen bewijs dat intra-veneuze albumine toediening enig effect heeft op de incidentie

van ernstig OHSS (OR 0.71, 95% BI 0.47 tot 1.07, 7 RCT’s , 1452 vrouwen, I2=55%, zeer

lage kwaliteit bewijs). Er was enig bewijs dat intra-veneuze albumine een positief effect heeft

op de incidentie van matige OHSS (OR 0.48, 95% BI 0.25 tot 0.90, 3 RCT’s , 1113 vrouwen,

I² = 41%, matige kwaliteit bewijs). Dit betekent dat als het risico op matige OHSS zonder

behandeling 14.3% is, het 4%-13% zal zijn met albumine. Als het risico op ernstige OHSS

zonder behandeling 16.2% is, zal het 8%-17% zijn met albumine. Hydroxyethyl starch zou de

incidentie van ernstige OHSS kunnen verminderen (OR 0.13, 95% BI 0.02 tot 0.75, 2

studies, 272 vrouwen, I2 =0%, matige kwaliteit bewijs). Er was een gunstig effect op matige

OHSS bij vrouwen die HES kregen, vergeleken met placebo (OR 0.33 95% BI 0.14 tot 0.75).

Dit betekent dat als het risico op matige OHSS zonder behandeling 13.2% is, het 2%-10% is

met HES. Als het risico op ernstige OHSS zonder behandeling 3.4% is, zal het tussen de

0.1-2.6% zijn. Er was ook enig bewijs dat mannitol de incidentie van ernstige OHSS kan

verlagen (OR 0.40, 95% BI 0.17 tot 0.91; 1 RCT, 226 vrouwen, matige kwaliteit bewijs), en

van matige OHSS (OR 0.50, 95% BI 0.28 tot 0.89; 1 RCT, 226 vrouwen, matige kwaliteit

bewijs). Dit betekent dat als het risico op matige OHSS zonder behandeling 36.2% is, het

tussen de 13.7%-33.6% zal liggen met mannitol. Als het risico op ernstige OHSS zonder

behandeling 15.5% is, zal het tussen de 3%-14.3% liggen met mannitol. Er was geen bewijs

voor enig effect op zwangerschapskans met albumine (OR 1.21 95% BI 0.83 tot 1.76, 7

RCT’s , 1452 vrouwen, I2=49%, en lage kwaliteit bewijs) of HES (OR 0.83, 95% B I0.34 tot

2.04, 1 RCT, 168 vrouwen, lage kwaliteit bewijs), of mannitol (OR 1.17 95% BI 0.65 tot 2.12;

1 RCT, 226 vrouwen, matige kwaliteit bewijs). Gegevens over levend geborenen werden in

geen enkele studie gerapporteerd. Nadelige effecten leken zelden voor te komen, maar

waren te slecht gerapporteerd om conclusies te trekken. We concluderen dat toediening van

intra-veneuze albumine geen effect heeft op de incidentie van ernstige OHSS, maar de

incidentie van matige OHSS verlaagt. Hydroxyethyl starch en mannitol zouden de incidentie

van zowel matige als ernstige OHSS kunnen verlagen. Er was geen bewijs dat albumine,

HES of mannitol enige invloed had op zwangerschapskansen.

In hoofdstuk 7 presenteren we een systematische review en meta-analysis dat een

overzicht geeft van de effectiviteit van ovariële stimulatie met lage doses gonadotrophines

voor vrouwen met een slechte ovariële reserve die IVF ondergaan . Conventionele ovariële

stimulatie regimes voor vrouwen met een slechte ovariële reserve bestaan uit hoge doses

232

FSH of HMG gecombineerd met verschillende protocollen GnRH analogen om een zo goed

mogelijke folliculogenese te verkrijgen. Desalniettemin blijft de eicelopbrengst, ondanks deze

hoge doses gonadotrophines, laag en is het percentage van de cycli dat moet worden

afgebroken hoog. Milde ovariële stimulatie regimes zijn voorgesteld als alternatief voor

vrouwen met een slechte ovariële reserve, met als doel de dosering van gonadotrophines te

reduceren of de duur van de stimulatie te verkorten met orale middelen zoals anti

oestrogenen of aromatase remmers, maar de gegevens hierover zijn nooit integraal

samengevat.

Wij doorzochten PubMed, EMBASE, Web of Science, de Cochrane Library and de Clinical

Trials Registry vanaf hun oprichting tot juni 2016. We includeerden gerandomiseerde

klinische trials (RCT’s ) die subfertiele vrouwen met slechte ovariële reserve includeerden en

ovariële stimulatie regimes met lage doseringen van gonadotrophines inclusief co-

behandeling met orale middelen als clomipheen citraat en letrozol, onafhankelijk van het

GnRH analogen protocol, vergeleken met ovariële stimulatie met hoge doses

gonadotrophines in het kader van IVF behandelingen. Iedere vergelijking tussen twee

verschillende doses gonadotrophines en combinaties van gonadotrophines met orale

middelen om de duur van de stimulatie te bekorten en daarmee de totale dosis

gonadotrophines was geschikt voor inclusie in ons review. We definieerden lage doses als

doses tussen de 150-300 IU per dag en hoge doses als doses tussen de 450-600 IU per

dag. Primaire uitkomstmaat was doorgaande zwangerschap. Secundaire uitkomstmaten

waren klinische zwangerschap, geboorte van een levend kind, duur gonadotrophine

stimulatie, totale dosering gonadotrophines, aantal cumulus–oocytes complexen (COCs),

aantal metaphase II (MII) oocyten, aantal embryo’s, aantal geplaatste embryo’s,

endometrium dikte op de dag van HCG en afbreken van de cyclus als gevolg van slechte

respons. We vonden 788 artikelen, screenden de titels en beoordeelden 36 studies als in

aanmerking te komen voor inclusie in de review. We excludeerden 21 studies; 14 na lezing

van de abstracts en vier omdat zij nog gaande waren. We includeerden dus 15 studies met

in het totaal 2183 vrouwen.

Zes studies vergeleken een lage dosering gonadotrophines met een hoge dosering van

gonadotrophines. Er was geen bewijs van een verschil in doorgaande zwangerschap (RR

1.05, 95% BI 0.70 tot 1.56; 4 RCT’s, I2 = 0%, matige kwaliteit bewijs), klinische

zwangerschap (RR 1.05, 95% BI 0.70 tot 1.56; 4 RCT’s, I2= 0 matige kwaliteit bewijs), en

geboorte van een levend kind (RR 0.85, 95% BI 0.37 tot 1.94; 2 RCT’s, I2 = 0%, matige

kwaliteit bewijs). Dit betekent dat voor een vrouw met 13% kans op een doorgaande

zwangerschap met het gebruik van hoge doses gonadotrophines, de kans op een

doorgaande zwangerschap met het gebruik van lage doses gonadotrophines tussen de 7 %

en 17 % zou zijn. De totale dosering van gonadotrophines die nodig was voor ovariële

233

stimulatie was significant verminderd bij vrouwen die werden behandeld met lage doses

gonadotrophines vergeleken met vrouwen die werden behandeld met hogedoses

gonadotrophines (WMD -2222 IU, 95% BI-2985 tot- 1459; 3 RCT’s, I2 = 99%). Er was geen

bewijs voor een verschil in stimulatie duur (WMD -1.3 dagen, 95% BI-1.23 tot 0.61; 3 RCT’s,

I2 = 88%). Er was een verschil in het aantal verkregen oocyten (COCs) ten gunste van hoge

doses gonadotrophines (WMD - 1.02 COCs, 95% BI-1.83 tot 0.22; 3 RCT’s. 1024, I2 = 96%).

Negen studies vergeleken ovariële stimulatie met gonadotrophines gecombineerd met de

orale middelen letrozole, (n=6) or clomiphene citraat (CC) (n=3) versus hoge doses

gonadotrophines. Er was geen bewijs van een verschil in doorgaande zwangerschap (RR:

0.90, 95% BI: 0.63 tot 1.27; 3 RCT’s I2 =0%) en klinische zwangerschap (RR 1.00, 95% BI

0.78 tot 1.28; 8 RCT’s, I2 =0%, matige kwaliteit bewijs). Dit betekent dat voor een vrouw met

een 13% kans op een doorgaande zwangerschap met het gebruik van gonadotrophines

alleen, de kans op een doorgaande zwangerschap met het gebruik van gonadotrophines

gecombineerd met orale middelen tussen de 7 % en 16 % zou zijn. De totale doses

gonadotrophines die nodig waren voor ovariële stimulatie was significant verminderd bij

vrouwen die waren behandeld met gonadotrophines gecombineerd met orale middelen

vergeleken met vrouwen die waren behandeld met gonadotrophines alleen (WMD: -2027

IUs, 95% BI-2583 tot- 1470: 9 RCT’s, I2= 98%). Significant minder stimulatie dagen waren

nodig bij vrouwen die waren behandeld met gonadotrophines gecombineerd met orale

middelen vergeleken met vrouwen die waren behandeld met gonadotrophines alleen (WMD -

1.79 dagen, 95% BI- 2.75 tot – 0, 84; 7 RCT’s, I2= 92%). Er was geen bewijs voor een

verschil in aantal verkregen oocyten tussen de vrouwen die waren behandeld met

gonadotrophines gecombineerd met orale middelen en de vrouwen die waren behandeld met

gonadotrophines alleen (WMD - 0.5 COCs, 95% BI- 1.41 tot 0.36; 9 RCT’s, I2= 91%). We

concluderen dat lage doses gonadotrophines of gonadotrophines gecombineerd met orale

middelen een alternatieve behandelingsmogelijkheid zijn bij vrouwen met slechte ovariële

reserve die IVF ondergaan.

In hoofdstuk 8 geven we de resultaten van een open-label multicenter gerandomiseerde

trial, ontworpen om een cyclus van een milde ovariële stimulatie strategie bestaande uit een

lage dosis gonadotrophines (150 IU FSH) en down regulatie van de hypofyse met een

GnRH-antagonist te vergelijken met een cyclus van een conventionele ovariële stimulatie

strategie bestaande uit hoge dosis gonadotrophines (450 IU HMG) en down regulatie van de

hypofyse met een lang mid luteale GnRH-agonist bij 394 oudere vrouwen en/of vrouwen met

slechte ovariële reserve die IVF ondergingen tussen mei 2011 en april 2014. Primaire

uitkomstmaat was doorgaande zwangerschap. Secundaire uitkomstmaten waren klinische

zwangerschap, biochemische zwangerschap, meerling zwangerschap, miskramen, aantal

234

oocyten, aantal metafase II oocyten, fertilisatie graad, aantal embryo’s, aantal embryo

transfers, totale FSH/HMG doses gebruikt tijdens de ovariële stimulatie, percentage

afgebroken cycli en drop-outs. Met een vooraf gedefinieerde non-inferioriteits marge van

10%, hetgeen betekent dat de bovengrens van het 95% betrouwbaarheidsinterval van het

absolute verschil tussen het primaire eindpunt in de twee studie groepen lager dan 10%

moet zijn. We bepaalden de groepsgrootte op basis van een verwacht doorgaand

zwangerschapspercentage in de conventionele strategie van 20%. Op basis van de chi-

square test en uitgaande van een 80% power om de vooraf gedefinieerde non-

inferioriteitsmarge bij een eenzijdige α waarde van 0.05 te detecteren, zouden we 177

vrouwen in iedere studie groep nodig hebben. Uitgaande van een follow-up verlies van 10%,

berekenden we de totale studie populatie op 394 vrouwen (197 per arm).

We wezen willekeurig 195 vrouwen toe aan de milde ovariële stimulatie strategie en 199

vrouwen aan de conventionele ovariële stimulatie strategie. Analyses waren op een

intention-to-treat basis. Doorgaande zwangerschap was 12.8% (25/195) versus 13.5% (27

/199) met een RR van 0.91 (95% BI 0.50-1.64).We vonden geen aanwijzingen voor een

verschil in klinische zwangerschap, miskraam, tweeling zwangerschap en conceptie. Een

extra-uteriene zwangerschap deed zich voor in iedere interventie arm. De duur van de

ovariële stimulatie was significant lager in de milde ovariële stimulatie strategie (8.42 ± 2.89)

vergeleken met de conventionele ovariële stimulatie strategie (9.67 ± 3.10) met een

gemiddeld verschil van min 1.2 dagen (95% BI-1.88 tot - 0.62). Significant lagere

hoeveelheden gonadotrophines werden gebruikt in de milde ovariële simulatie strategie, met

een gemiddeld verschil van min 3135 IU (95% BI:-3331 tot -2940). Op de dag van HCG was

het aantal follikels ≥ 15 mm significant lager in de milde ovariële stimulatie strategie

vergeleken met de conventionele ovariële simulatie strategie met een gemiddeld verschil van

min 1.2 follikels (95% BI-1.88 tot - 0.55). In de milde ovariële stimulatie strategie waren 52

(26%) cycli gecanceld en 37 (18%) cycli in de conventionele ovariële stimulatie strategie (RR

1.5; 95% BI 0.96 - 2.5). De milde ovariële stimulatie strategie resulteerde in significant

minder oocyten (3.3 ± 2.0 vs. 5.0 ± 4.0) en minder rijpe oocyten (MII) (2.7± 2.0 vs. 4.0 ±3.0,).

Er waren minder gefertiliseerde oocyten (2.4 ± 2.0 vs. 3.4 ± 3.0), en embryo’s (2.0 ± 1.9 vs.

2.7 ± 2.4) maar het aantal top kwaliteit embryo’s (0.8 ± 1.1 vs. 0.8 ± 1.2) en het aantal

geplaatste embryo’s (0.8 ± 1.3 vs. 0.8 ± 1.2) waren gelijk. De kracht van deze studie ligt in de

vergelijking tussen twee strategieën van ovariële stimulatie bij vrouwen met een slechte

ovariële reserve in een grote multicenter internationale RCT met centrale randomisatie

waarbij de laagste dosering FSH ooit gebruikt in een GnRH antagonist protocol wordt

vergeleken met conventionele ovariële stimulatie met hoge doses van 450 IU HMG.

Bovendien werd de dosering verhoogd noch verlaagd tijdens de stimulatie fase. Een

235

beperking van onze studie was het gebrek aan gegevens over cryopreservatie van

boventallige embryo’s, dus hebben we geen informatie over cumulatieve

zwangerschapskansen. Maar, omdat het aantal top kwaliteit embryo’s en geplaatste

embryo’s vergelijkbaar was, was per extrapolatie, het aantal ingevroren embryo’s

waarschijnlijk gelijk verdeeld tussen de twee strategieën en gezien de slechte ovariële

respons, gering in aantal. Een andere beperking is dat we geen follow up hebben van de

doorgaande zwangerschappen in alle centra, dus we hebben geen informatie over de levend

geborenen.

We concluderen dat een milde ovariële stimulatie strategie niet inferieur is aan conventionele

ovariële stimulatie in termen van zwangerschapsuitkomsten. Dus zou milde ovariële

stimulatie de behandeling van eerste keus moeten zijn bij vrouwen die IVF ondergaan met

een slechte ovariële reserve.

Klinische implicaties

Vrouwen die een risico lopen op OHSS kunnen worden behandeld met een GnRH

antagonist protocol dat in zichzelf al zal leiden tot een mildere ovariële respons vergeleken

met een lang GnRH agonist protocol. In geval er dan nog steeds een risico op OHSS is, kan

een GnRH agonist worden gegeven als ovulatie trigger met cryopreservatie van alle

embryo’s. Echter, ondanks dit behandeling regime is een enkele keer toch ernstige OHSS

beschreven. Dus, voorzichtigheid is geboden, ook bij de GnRH agonist trigger. In dit opzicht

zou het van waarde kunnen zijn om high responders voor het begin van de stimulatie te

identificeren en de FSH dosering aan te passen.

Wij hebben ook aangetoond dat het gebruik van de dopamine agonist Cabergoline de kans

op OHSS met 50% reduceert; maar de agonist wordt niet vaak gebruikt omdat het alleen

effectief is bij de preventie van milde en vroege OHSS, en niet van ernstige of late OHSS.

Wij adviseren dan ook niet om een dopamine agonist te gebruiken. Toediening van intra-

veneus albumine verlaagt het risico op ernstige OHSS niet en moet dan ook niet worden

aanbevolen om OHSS te voorkomen. Hydroxyethyl starch en mannitol zouden de incidentie

van matige en ernstige OHSS kunnen voorkomen. Zij zijn goedkoper en zijn als niet

biologische colloidale vloeistoffen vrij van de risico’s geassocieerd met albumine. Dus raden

we het gebruik van deze middelen aan in plaats van humaan albumine om de ernst van

OHSS te reduceren.

We hebben aangetoond dat vrouwen met een slechte ovariële reserve baat kunnen hebben

van een behandeling met lage doses gonadotrophines- ≈ 150 IU- of gecombineerd met orale

middelen – clomipheen citraat of letrozol- met of zonder aanpassing van de dosis. Milde

236

ovariële stimulatie zou dan ook de interventie van keus moeten zijn in plaats van

conventionele ovariële stimulatie met hoge doses gonadotrophines. Dit kan leiden tot

aanzienlijke kosten besparing.

Implicaties voor toekomstig onderzoek

Het is misschien meer waardevol om toekomstig onderzoek te richten op de individualisatie

van ovariële stimulatie en IVF behandelingsprotocollen aan te passen om de uitkomsten te

verbeteren in de zin van een toegenomen kans op de geboorte van een levend kind en een

afgenomen kans op OHSS, meerling zwangerschappen, belasting van de patiënt en kosten.

Een direct voordeel van individualisatie van de behandeling in termen van toegenomen kans

op zwangerschap en betere kosten effectiviteit moet overigens nog worden vastgesteld.

Toekomstige studies die zich richten op de individualisatie van de behandeling en kosten

effectiviteit voor de preventie van OHSS en vermindering van de kosten van behandeling van

vrouwen met slechte ovariële reserve zouden hier meer inzicht in kunnen verschaffen. Goed

gepowerde studies zijn nodig om de strategie van milde ovariële stimulatie te beoordelen bij

slechte en goede responders met verschillende geneesmiddelen, doses gonadotrophines en

GnRH analogen om een goede balans te bereiken tussen IVF succes, belasting van de

behandeling, complicaties en kosten.

De vraag is of paren zullen deelnemen aan dergelijke trials of dat zij zich tot commerciële

klinieken zullen wenden voor conventionele behandeling, als zij gerandomiseerd zijn voor

milde ovariële stimulatie. Dus een goed begrip van de overwegingen die vrouwen hebben bij

het bepalen van hun voorkeuren wat betreft milde ovariële stimulatie zou kunnen bijdragen

tot verbetering van de counseling en gedeelde besluitvorming. Studies naar patiënten

voorkeur in de vorm van “discrete choice” experimenten om de perspectieven van vrouwen

te onderzoeken op het gebied van milde stimulatie met lage doses gonadotrophines met of

zonder orale middelen met betrekking tot levend geborenen en kosten zouden kunnen

worden gestart zowel bij vrouwen met een slechte als een goede ovariële reserve. Hetzelfde

geldt voor de GnRH agonist trigger in antagonisten cycli gevolgd door cryopreservatie van

alle embryo’s. Studies zijn nodig om de voorkeuren van patiënten te evalueren over de

GnRH agonist trigger in het licht van de lage zwangerschapskans en de noodzakelijkheid om

de embryo’s in te vriezen.

De studies gepresenteerd in dit proefschrift die verschillende preventieve strategieën bij

OHSS evalueerden, lieten geen ideale uitkomsten zien. Toediening van albumin als volume

expander had geen substantieel effect bij het voorkomen van ernstige OHSS bij subfertile

vrouwen die ovariële stimulatie ondergingen in het kader van een IVF behandeling. We

bevelen dan ook geen verdere evaluatie aan van het gebruik van albumin ter preventie van

237

OHSS. De weinige studies die Hydroxyethyl starch en mannitol evalueerden hebben een

substantieel effect getoond bij de vermindering van matige tot ernstige OHSS. Dus is verder

onderzoek nodig om te verifiëren of deze intra-veneuze vloeistoffen hun belofte waarmaken.

Ook is een uitgebreid netwerk meta-analyse nodig om de preventieve werking van de meest

bekende regimes op OHSS te vergelijken en om het effect van deze behandelingen op de

kans op zwangerschap na ART in te schatten. Voor andere interventies zoals intraveneuze

calcium infusie zijn meer studies nodig om kosten effectiviteit en veiligheid te beoordelen. Tot

slot, de precieze onderliggende pathofysiologie van OHSS is niet duidelijk. Meer studies zijn

nodig om de pathofysiologie van deze aandoening op te helderen.

238

References

• Boivin J, Bunting L, Collins JA, Nygren KG. International estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical care. Hum Reprod. 2007; 22(6):1506-12.


• Baumgarten M, Polanski L, Campbell B, Raine-Fenning N. Do dopamine agonistsprevent or reduce the severity of ovarian hyperstimulation syndrome in women undergoing assisted reproduction? A systematic review and meta-analysis. Hum Fertil 2013; 16(3):168-74.



• D'Angelo A, Brown J, Amso NN. Coasting (withholding gonadotrophins) for preventing ovarian hyperstimulation syndrome. Cochrane Database Syst Rev. 2011 15;(6):CD002811.

• de Boer EJ, Den Tonkelaar I, Burger CW, Looman CW, van Leeuwen FE, te Velde ER; The number of retrieved oocytes does not decrease during consecutive gonadotrophin-stimulated IVF cycles. OMEGA project group. Hum Reprod. 2004;19(4):899-904.




• Heijnen EM, Eijkemans MJ, De Klerk C, Polinder S, Beckers NG, Klinkert ER, Broekmans FJ, Passchier J, Te Velde ER, Macklon NS, Fauser BC. A mild treatment strategy for in-vitro fertilisation: a randomised non-inferiority trial. Lancet 2007; 369 (9563): 743–749.


239

• Onofriescu A, Bors A, Luca A, Holicov M, Onofriescu M, Vulpoi C GnRH Antagonist IVF Protocol in PCOS. Curr Health Sci J. 2013;39(1):20-5.






240

Appendices

241

List of co-authors and affiliations

Aboulfoutouh I, Department of Obstetrics & Gynecology, Faculty of Medicine, Cairo University,

Egypt

Aboulghar M, Department of Obstetrics & Gynecology, Faculty of Medicine, Cairo University,

Egypt

Abou- Setta AM, University of Alberta Evidence-based Practice Centre (UA-EPC), Alberta Research

Centre for Health Evidence (ARCHE), Edmonton, Canada

Akhondi M, Reproductive Biotechnology Research Center, Avicenna Research Institute,

Tehran, Iran

Alhalabi M, Division of Embryology and Reproductive Medicine, Faculty of Medicine, and

Assisted Reproduction Unit, Orient Hospital, Damascus, Syria

Al-inany H, Department of Obstetrics & Gynecology, Faculty of Medicine, Cairo University,

Egypt

Ansaripour S, Reproductive Biotechnology Research Center, Avicenna Research Institute, Tehran,

Iran

Ayeleke RO, Department of Obstetrics & Gynecology, University of Auckland, Cairo University,

New Zealand

Broekmans FJ, Department of Reproductive Medicine and Gynecology, University Medical Center,

Utrecht, Netherlands

Brown J, Liggins institute, University of Auckland, New Zealand

El-Mohamedy M, Department of Obstetrics & Gynecology, Faculty of Medicine, Cairo University,

Egypt

Fouda UM, Department of Obstetrics & Gynecology, Faculty of Medicine, Cairo University,

Egypt

Griesinger G, 5UK-SH, Campus Luebeck, Luebeck, Germany

Jahangiri N, Department of Endocrinology and Female Infertility, Reproductive Biomedicine

Research Center, Royan Institute for Reproductive Biomedicine, Tehran, Iran

Hassan M, Department of Obstetrics & Gynecology, Faculty of Medicine, El-fayoum University,

242

Egypt

Khattab M, Department of Obstetrics & Gynecology, Faculty of Medicine, Cairo University,

Egypt

Khodabakhshi S, Reproductive Biotechnology Research Center, Avicenna Research Institute, Tehran,

Iran

Lam WS, Department of Obstetrics & Gynecology, University of Auckland, Cairo University,

New Zealand

Madani T, Department of Endocrinology and Female Infertility, Reproductive Biomedicine

Research Center, Royan Institute for Reproductive Biomedicine, Tehran, Iran

Mochtar M, Centre for Reproductive Medicine, Academic Medical Centre, University of

Amsterdam, Netherlands

Mourad S Radboud University Medical center, Nijmegen, Netherlands

Nagi Mohesen M, Department of Obstetrics & Gynecology, Faculty of Medicine, Beni-suef University,

Egypt

Rizk A, Department of Obstetrics & Gynecology, Faculty of Medicine, Banha University,

Egypt

Shaeer E, Department of Obstetrics & Gynecology, Faculty of Medicine, Cairo University,

Egypt

Shaltout A, Department of Obstetrics & Gynecology, Faculty of Medicine, Cairo University,

Egypt

Shohyab A, Department of Obstetrics & Gynecology, Faculty of Medicine, Cairo University,

Egypt

Tokhmechy R, Reproductive Biotechnology Research Center, Avicenna Research Institute, Tehran,

Iran

van der Veen F, Centre for Reproductive Medicine, Academic Medical Centre, University of


van Wely M, Centre for Reproductive Medicine, Academic Medical Centre, University of


243

Zarandi L, Reproductive Biotechnology Research Center, Avicenna Research Institute, Tehran,

Iran

244

List of publications

1. Fouda UM, Sayed AM, Elshaer HS, Hammad BE, Shaban MM, Elsetohy KA, Youssef MA. GnRH antagonist rescue protocol combined with cabergoline versus cabergoline alone in the prevention of ovarian hyperstimulation syndrome: a randomized controlled trial. J Ovarian Res. 2016; 9 (1):29.

2. Youssef MA, Abou-Setta AM, Lam WS. Recombinant versus urinary human chorionic gonadotrophin for final oocyte maturation triggering in IVF and ICSI cycles.Cochrane Database Syst Rev. 2016; 4:CD003719.

3. Youssef MA, Abdelsalam L, Harfoush RA, Talaat IM, Elkattan E, Mohey A, Abdella RM, Farhan MS, Foad HA, Elsayed AM, Elkinaai NA, Ghaith D, Rashed ME, Ghafar MA, Khamis Y, Hosni AN. Prevalence of human papilloma virus (HPV) and its genotypes in cervical specimens of Egyptian women by linear array HPV genotyping test.Infect Agent Cancer. 2016;11:6

4. Youssef MM, Mantikou E, van Wely M, Van der Veen F, Al-Inany HG, Repping S,Mastenbroek S. Culture media for human pre-implantation embryos in assisted reproductive technology cycles. Cochrane Database Syst Rev. 2015;11:CD007876.

5. Youssef MA, Van der Veen F, Al-Inany HG, Mochtar MH, Griesinger G, Aboulfoutoh I, van Wely M. The updated Cochrane review 2014 on GnRH agonist trigger: an indispensable piece of information for the clinician.Reprod Biomed Online.2016;32(2):259-60

6. Abdelmoty HI, Youssef MA, Abdallah S, Abdel-Malak K, Hashish NM, Samir D,Abdelbar M, Hosni AN, Abd-El Ghafar M, Khamis Y, Seleem M. Menstrual patternsand disorders among secondary school adolescents in Egypt. A cross-sectionalsurvey. BMC Womens Health. 2015; 15:70.

7. Abdelbary AM, El-Dessoukey AA, Massoud AM, Moussa AS, Zayed AS, Elsheikh MG, Ghoneima W, Abdella R, Yousef M. Combined Vaginal Pelvic Floor Electrical Stimulation (PFS) and Local Vaginal Estrogen for Treatment of Overactive Bladder (OAB) in Perimenopausal Females. Randomized Controlled Trial (RCT). Urology.2015 Sep; 86(3):482-6. doi: 10.1016/j.urology.2015.06.007

8. Rana M. A. Abdella, Hatem I. Abdelmoaty, Rasha H. Elsherif, Ahmed Mahmoud Sayed, Nadine Alaa Sherif, Hisham M. Gouda, Ahmed El Lithy, Maged Almohamady,Mostafa Abdelbar, Ahmed Naguib Hosni, Ahmed Magdy, and Youssef MA. Screening for Chlamydia trachomatis in Egyptian women with unexplained infertility, comparing real-time PCR techniques to standard serology tests: case control study. BMC Womens Health. 2015; 15: 45.

9. Ghada Abdel Fattah Abdel Moety, Maged Almohamedy, Nadine Alaa Sherif, Aymen N.Rasalan, Tarek Fawazy Mohamed, Hazem Mohamed Abdel Mohsen, Abeer Mohamed Mohy, and Mohamed A.F.M.Youssef. Could first-trimester assessment of placental functions predict preeclampsia and intrauterine growth restriction? A prospective cohort study. J Matern Fetal Neonatal Med. 2016;29(3):413-7

10. Youssef MA, Abdelmoty HI, Elashmwi HA, Abduljawad EM, Elghamary N, Magdy A, Mohesen MN, Abdella RM, Bar MA, Gouda HM, Ali AM, Raslan AN, Youssef D, Sherif NA, Ismail AI. Oral antioxidants supplementation for women with unexplained

245

infertility undergoing ICSI/IVF: Randomized controlled trial. Hum Fertil (Camb). 2015 Mar;18(1):38-42.

11. Hashish N, Hassan A, El-Semary A, Gohar R, Youssef MA. Could 3D placental volume and perfusion indices measured at 11-14 weeks predict occurrence of preeclampsia in high-risk pregnant women? J Matern Fetal Neonatal Med.2015;28(9):1094-8.

12. Saleh WF, Gamaleldin SF, Abdelmoty HI, Raslan AN, Fouda UM, Mohesen MN, Youssef MA. Reproductive health and HIV awareness among newly married Egyptian couples without formal education. Int J Gynaecol Obstet. 2014; 126(3):209-12.

13. Hashish NM, Badway HS, Abdelmoty HI, Mowafy A, Youssef MA. Does flushing the endometrial cavity with follicular fluid after oocyte retrieval affect pregnancy rates in subfertile women undergoing intracytoplasmic sperm injection? A randomizedcontrolled trial. Eur J Obstet Gynecol Reprod Biol. 2014; 176:153-7.

14. Abdel-Mohsen IIK, Youssef MAFM, Elashmwi H, Darwish A, Khattab SM (2013) Clomiphene Citrate plus Modified GnRH Antagonist Protocol for Women with Poor Ovarian Response Undergoing ICSI Treatment Cycles: Randomized Controlled Trial. Gynecol Obstet 3:158.

15. Mantikou E, Youssef MA, van Wely M, van der Veen F, Al-Inany HG, Repping S,Mastenbroek S. Embryo culture media and IVF/ICSI success rates: a systematic review. Hum Reprod Update. 2013; 19(3):210-20.

16. Samah Aboul Gheit, Ahmed Naguib Hosny, Mahmoud Sedki Yassin,Shahira Gemei,Mostafa Ahmed Zaki Shokry, Mohamed AFM Youssef Argon beam coagulator versus cystectomy for endometrioma treatment in infertile women and the impact on ovarian reserve. A case control study. MEFS. 2013; 19 (1): 22-25.

17. Mohamed A.F.M. Youssef: Is evidence based medicine (EBM) applicable in our reallife? Middle East Fertility Society Journal 2013; 18 93); 217-219.

18. Mahmoud Youssef MA, van Wely M, Aboulfoutouh I, El-Khyat W, van der Veen F,Al-Inany H. Is there a place for corifollitropin alfa in IVF/ICSI cycles? A systematic review and meta-analysis. Fertil Steril. 2012.

19. Mohamed A.F.M. Youssef: Obstructed hemivagina and ipsilateral renal anomaly syndrome with uterus didelphys (OHVIRA). Middle East Fertility Society Journal 2013; 18 (1):58-61

20. Sherif M. Khattab, Mohamed Abdel Fattah Mahmoud Youssef. Primary anterior vaginal wall pure ammonium acid urate stone. Case report. Middle East Fertility Society Journal 2013; 18(3): 217-219.

21. Tarek A. A. Moussa, Rasha Hamed Elsherif, Youssef Abdelfattah Mohamed,Mohamed E. A. Dawoud and Asmaa Mohamed AboElAref. Group B streptococcus colonization of pregnant women: comparative molecular and microbiological diagnosis. Comparative Clinical Pathology 2013; 22 (6): 1229-1234.

22. Rasha Hamed Elsherif and Mohamed Abdl Fatah Youssef. Real-time PCR improve detection of Trichomonas vaginalis compared to conventional techniques.

246

Comparative Clinical Pathology. 2013; 22 (2): 295-300.

23. Mohamed AFM Youssef: The Controversy Over the Final Maturation Trigger in GnRH Antagonist Treated IVF/ICSI Cycles. KAJOG 2012

24. Mohamed AFM Youssef et al., Mild ovarian stimulation in women with poor ovarian response undergoing IVF and ICS. Evidence Based Women’s Health Society 2012.

25. Mohamed Abdelfattah Mahmoud Youssef. Peer review of manuscript submitted to medical journals. Middle East Fertility Society Journal 2012; 17 (2): 139-143

26. Al-Inany HG, Youssef MA, Aboulghar M, Broekmans F, Sterrenburg M, Smit J, Abou-Setta AM. GnRH antagonists are safer than agonists: an update of a Cochrane review. Hum Reprod Update. 2011 Jul-Aug; 17(4):435. Review. PubMed PMID: 21646384.

27. Al-Inany HG, Youssef MA, Aboulghar M, Broekmans F, Sterrenburg M, Smit J, Abou-Setta AM. Gonadotrophin-releasing hormone antagonists for assisted reproductive technology. Cochrane Database Syst Rev. 2011 ;( 5):CD001750.

28. Youssef MA, Al-Inany HG, Aboulghar M, Mansour R, Abou-Setta AM. Recombinant versus urinary human chorionic gonadotrophin for final oocyte maturation triggering in IVF and ICSI cycles. Cochrane Database Syst Rev. 2011;(4):CD003719.

29. Youssef MA, Al-Inany HG, Evers JL, Aboulghar M. Intra-venous fluids for the prevention of severe ovarian hyperstimulation syndrome. Cochrane Database Syst Rev. 2011 ;( 2):CD001302.

30. Aboulfotouh II, Youssef MA, Mady AF, Abdelhak AM, Khattab SM. Non-mosaic Klinefelter syndrome and successful testicular sperm extraction-intracytoplasmic sperm injection procedure: case report. Gynecol Endocrinol. 2011; 27(11):874-5.

31. Khattab S, Mohsen IA, Aboul Foutouh I, Ashmawi HS, Mohsen MN, van Wely M, van der Veen F, Youssef MA. Can metformin reduce the incidence of gestational diabetes mellitus in pregnant women with polycystic ovary syndrome? Prospective cohort study. Gynecol Endocrinol. 2011; 27(10):789-93.

32. Youssef MA, Van der Veen F, Al-Inany HG, Griesinger G, Mochtar MH, van Wely M. Gonadotropin-releasing hormone agonist versus HCG for oocyte triggering in antagonist assisted reproductive technology cycles. Cochrane Database Syst Rev. 2010; (11):CD008046.

33. M.A.F Youssef. Effective sample size calculation: How many patients will I need to include in my study? Middle East Fertility Society Journal, (2011) 16, 295–296

34. Abdelrahman Elnashar, Amr M. Gadallah, Alaa A. Abdelaal, Islam F. Soliman, Mohamed A.F.M. Youssef. Can the International Index of Erectile Function (IIEF-5) be used as a diagnostic tool to the severity of vasculogenic erectile dysfunction? Middle East Fertility Society Journal 2012; 17:101–104.

247

PORTFOLIO

Workshops

2014 Training of Trainers "ToT" organized by the German Academic Exchange Service (DAAD), Cairo

2014 Change Agents for Egypt-Network Activity for Future University Leaders. the German Academic Exchange Service (DAAD), Cairo

2013 UNILEAD Egypt program: University Leadership and Management Training Course by the German Academic Exchange Service (DAAD), Cairo and the Carl von Ossietzky University of Oldenburg in Germany.

2013 Project management professional training course in Cairo by Knowledge Huthttp://www.knowledgehut.com/course/302/PMP/Egypt/901/workshop-Dec

2013 Improving standards - Adapting RCOG guidelines for local use workshop arranged by RCOG at 1st FIGO Africa Regional Conference of Gynaecology and Obstetrics. October 2-5, 2013 • Addis Ababa, Ethiopia

2013 Pre-congress course 12: Task Force Management of Fertility Units in conjunction with the Special Interest Groups Andrology / Embryology / Reproductive Surgery & Safety and Quality in ART “Total quality management (TQM) in an IVF Centre” organized by ESHRE -2013-UK

2013 “ Your Future in Science: Writing and Publishing a Scientific Paper “organized by Prof. Dr. Mary M. Christopher at JARCU-Cairo University - Egypt 23 April 2013

2013 “Evidence based medicine in clinical Drug safety and Effectiveness” organized by FDA at Cairo University from 8-9 April 2013

2013 Pre-congress workshop-(Assisted reproductive technology) - Cairo University- Cairo- Egypt. As speaker

2012 “ Authorship and Reviewing “ presented by Ewa Kittel-Prejs Journals Publishing Director Elsevier and organized by the Academy of Scientific Research and Technology

2012 “ Biostatistics II academics” online course organized by Statistics.com

2012 “Power-analysis for Cluster-randomized and Multi-site Studies" online course organized by Statistics.com

2012 German Academic Exchange Service (DAAD) Funding Opportunities and How to evaluate candidates for DAAD. At Kasr Al-Aini Conference Center, Hall B, 28th May 2012

2012 How to write a proposal: The Technical Support Office for projects & Grants in collaboration with German Scientific Exchange Service (DAAD). Monday 4 June 2012, from 9:00 am -4:00 pm. Venue: Learning Resource Center (LRC) at Kasr AlAiny

2011 UNFPA Arab States Regional Office “Reproductive Health and Health Systems Strengthening Synergies” Workshop (29 May 2011- 02 June 2011) organized by Maha El-Adawy, RH Technical Advisor, UNFPA, ASRO Margaret Kruk, Columbia University

248

2012Pre-congress workshop-(Assisted reproductive technology) - Cairo University- Cairo- Egypt. As speaker

2012Pre-congress workshop (Intensive Workshop in Urogynecology and Reconstructive Pelvic Surgery)10-12 April 2011- Cairo University- organizing committee and speaker

2011Pre-congress workshop-(Assisted reproductive technology) - Cairo University- Cairo- Egypt. As speaker

2011Pre-congress workshop (Intensive Workshop in Urogynecology and Reconstructive Pelvic Surgery)10-12 April 2011- Cairo University- organizing committee and speaker

2010 Training workshop for journal editors organized by Prof. Dr. Mary M. Christopher at STMPU-Cairo -Egypt

2009 Advanced clinical epidemiology course- University of Amsterdam (UVA)-Netherlands.

2009 Oral presentation course - University of Amsterdam (UVA)-Netherlands.

2009 Clinical data management - University of Amsterdam (UVA)-Netherlands.

2009 Basic course “the AMC World of Science”- University of Amsterdam (UVA) - Netherlands.

2009 Mild IVF precongress course - ESHRE - Amsterdam - Netherlands

2009 Pub Med biomedical sciences University of Amsterdam (UVA)-Netherlands

2009 Reference Manager 12 Advanced course. University of Amsterdam (UVA)-Netherlands

2008 Cochrane database Workshop – Dutch Cochrane Centre- University of Amsterdam (UVA)-Netherlands.

2008 Scientific Writing Workshop- University of Amsterdam (UVA)-Netherlands.

2008 Evidence based medicine course- how to use Pub med, Web of science and Reference manager -University of Amsterdam (UVA)-Netherlands.

2008 Essential clinical epidemiology course- University of Amsterdam (UVA)-Netherlands.

2008 Practical and advanced biostatistics course- University of Amsterdam (UVA)-Netherlands.

2004 Evidence based medicine course- Cairo university- Egypt

2004 Quality control course - Cairo University – Egypt

249

Oral and poster presentations

2015 The 31th Annual Meeting of European Society of Human Reproduction &Embryology - Lisbon 2015.

2015 The 29th Annual scientific meeting for obstetrics & gynaecology department- Faculty of Medicine-Alexandria University, Egypt. Oral presentation- Speaker

2014 21th Annual meeting of Middle East Fertility Society (MEFS) - Dubai- UAE-2014, 2oral presentations & chairperson

2014 The 30th Annual Meeting of European Society of Human Reproduction &Embryology - Munich 2014. 1oral presentation accepted

2014 11th International Symposium on GnRH the hypothalamic-pituitary-gonadal axis in cancer and reproduction- Salzburg- Austria: Accepted oral presentation, Speaker

2014 Ismailia Obstetrics & Gynaecology Syndicate symposium

2014 8th Annual Meeting of Department of Obstetrics & Gynaecology- Sohag University

2014 Annual Meeting of department of Obstetrics& Gynaecology- South Vally University

2013 1st FIGO Africa Regional Conference of Gynaecology and Obstetrics. October 2-5, 2013 • Addis Ababa, Ethiopia. 2 Oral presentations, Speaker & chairperson

2013The 69th ASRM Annual Meeting - Boston-USA. 3 Poster presentations

2013The 29th Annual Meeting of European Society of Human Reproduction &Embryology - London 2013.1 poster presentation

20131st International Medical writing congress- Dubai-UAE- Oral presentation, Speaker

2013The third Annual International Meeting of Egyptian Representative Committee ERC, Egypt, oral presentation – Oral presentation, Speaker

2013The 27th Annual scientific meeting for obstetrics & gynaecology department- Faculty of Medicine-Alexandria University, Egypt.3-4 May 2012- Oral presentation- Speaker

201311th annual meeting of obstetrics & gynaecology departments - Faculty of Medicine-Al- Azhar University, Egypt. 2 Oral presentations& Speaker

201212nth Annual Scientific Meeting for Obstetrics & Gynaecology, Department Faculty of Medicine - Cairo University, Egypt: oral presentations & Speaker

2012The Egyptian fertility society conference- Cairo -Egypt. 1 Oral presentation & Speaker

201219th Annual meeting of Middle East Fertility Society (MEFS) - Dubai- UAE-2013, 2oral presentations & speaker

2012The 28th Annual Meeting of European Society of Human Reproduction &- Istanbul 2012. 2 POSTERS presentations

201210th annual meeting of obstetrics & gynaecology departments-Faculty of Medicine- Al-Azhar University, Egypt. June 14-15/2012- Oral presentation & speaker

250

2012The Second Annual International Meeting of Egyptian Representative Committee ERC, Egypt, oral presentation – Oral presentation & speaker

2012 26th Annual scientific meeting for obstetrics & gynecology department- Faculty of Medicine-Alexandria University, Egypt. 3-4 May 2012- oral presentations andspeaker

2012 11nth Annual Scientific Meeting For Obstetrics & Gynecology Department Faculty of Medicine - Cairo University, Egypt : oral presentations& speaker

2011 18th Annual meeting of Middle East Fertility Society – Lebanon, 2 oral presentations &speaker

2011 67th ASRM (American society of reproductive medicine- USA ): 3 posters presentation

2011 7th Royan International Twin Congress Reproductive Biomedicine & Stem Cell-Tehran Iran

2011 The 27th Annual Meeting of European Society of Human Reproduction- Stockholm-SWEDEN: 2 oral presentations and speaker

2011 25th Annual Scientific Meeting For Obstetrics & Gynecology Department Faculty of Medicine - Alexandria University 4-6 May 2011 : 2 oral presentations and speaker

2011 Alexandria workshop for women health, oral presentation

2011 10nth Annual Scientific Meeting For Obstetrics & Gynecology Department Faculty of Medicine - Cairo University : oral presentations & speaker

2011 10th International Symposium on GnRH the hypothalamic-pituitary-gonadal axis in cancer and reproduction- Salzburg- Austria: 2 oral presentation, speaker and 1 poster

2010 The 28th Annual Meeting of European Society of Human Reproduction- ROME): 2oral presentations & speaker

2010 66th ASRM (American society of reproductive medicine ASRM (American society of reproductive medicine): poster presentation

2010 17th Annual meeting of Middle east fertility society- Damascus: 3 oral presentations &speaker

2009 The 27th Annual Meeting of European Society of Human Reproduction &ESHRE -Amsterdam - Netherlands. Oral presentation

2010 9nth Annual Scientific Meeting For Obstetrics & Gynaecology Department Faculty of Medicine - Cairo University : Oral presentation & speaker

2010 Suzan Mubarak for women health and development ,Alexandria conference- Oral presentation& speaker

2009 ESHRE (European society for human reproduction and embryology) - Amsterdam -Netherlands. Oral presentation (01 July 2009)

251

Awards and grants

2016 Incentive award of state Egypt

2016 International publication awards Cairo University, Egypt

2015 Middle East Fertility society conference (Dr. samir Abbas Award)

Sharm Elshikh-Egypt

2015 International Publication Miser Elkhair Foundation, Egypt

2015 International publication awards Cairo University , Egypt

2014 Best poster presentation Award Egyptian Fertility & Sterility Society (EFSS)- Egypt


2013 State award “ Dr. Mohamed Fakhry Mekawy” Science & technology & development foundation ( STDF)


2012 Merck Sorono Infertility innovation award Egyptian fertility society

2012 Cairo University incentive award Cairo University, Egypt


2012 Egyptian grant for post MD research Egypt

2011 Award of the best article presented at middle east fertility society conference

MEFS conference - Lebanon

2011 International publication awards Cairo University , Egypt


2013 STDF grant for short term fellowships Science & technology & development foundation ( STDF)

2011 NUFFIC Grant for Reproductive Medicine PhD Netherlands

2010 Grant for clinical & research fellowship at AMC-Center for Reproductive Medicine- Amsterdam- Netherlands

Egypt

252

Acknowledgements

My interest in the female infertility & assisted reproduction arena started to grow since the

early beginnings of my residency in Cairo university hospital. Since then, I started a non-stop

quest for a learning opportunity in this field. Fortunately, I landed on an Egyptian grant which

allowed me to carry out my MD research project in the field of my passion, in addition to a

training opportunity abroad. Then I started to contact many experts in the field. I was thrilled

when I got a reply from Prof. dr. Fulco with his acceptance to supervise my research project

in the AMC.

Fulco, Madelon and Monique, I would like to express my deep gratitude for the opportunity;

not only did I come to work in a topic that I love but I was also part of a big dynamic and

diverse team. It has always been a pleasure to work with you, facing the challenges that

came our way. You have contributed in many ways to this thesis.

Fulco, - the dignified mentor of CVV- you taught me the secrets of proper scientific thinking,

writing and how to incorporate evidence based medicine in my daily practice with patients.

You give me the opportunity to be part of your team for more than 8 years and encouraged

me to proceed in my PhD projects with patience. I learned from you how to be enthusiastic

and persistent to do my work perfectly. Your advice on both research, as well as my career

has been priceless. When I went back to Egypt in 2010, you advised me to establish my

team and try to continue my research work and to expand my knowledge and experience.

You supported me and my colleagues to hold our first symposium “Upper Egypt ART” which

was successful and fruitful. I could not wish for a better advisor and mentor for my Ph.D

study; it was a truly life changing opportunity for me.

Madelon “Bescherm angel” I cannot have enough words to express my gratitude to the effort

and time that you spent to teach me how to write a manuscript, understand statistics and

how to deal with reviewers and editors comments. You always solved my problems and fixed

my frequent mistakes with your warm smile and kind heart. I would like to greatly thank you

for answering all my questions whenever I brought them to you. Not only that, I cannot forget

how much you helped me to overcome my stress and disappointments during my first year in

AMC, you were always concerned about me and my family.

Monique, the strong and dynamic lady of CVV, you monitored my first ovum-pickup training

attempts in CVV clinic. I would like thank you for your continuous support during my Ph.D

research, for your patience, motivation, and immense knowledge. Your guidance helped me

during the research work and writing of this thesis. You spent a lot of time editing many

253

manuscripts included in this thesis, you used to give me the hope that this work will come to

light soon & here it is.

Hesham -my great professor-, I would like to express my sincere gratitude for your

continuous support to me when I was in the AMC. You are the first person who helped me to

come to Netherlands, meet Fulco and start my entire career in the AMC. You spent many

days showing to me what should I do and what is the best way to be a good clinician, as well

as a researcher. Because of your professional network, many IVF centers accepted to

participate in PRIMA study, the topic of my PhD. Without your help & continuous persistence

& negotiation, I would not be able to defence my PhD.

Beatrix and Marjolein, you have always been there for me, I would like to thank you for your

valuable help on all administrative works of my thesis. Of course, this was only a small part

of your continuous help you kindly offered me, which I’ll never forget and will always be

grateful to you.

I would like to thank the rest of my committee members, Prof. dr. Broekmans, Prof. dr.

Elgindy, Prof. dr. Goddijn, Dr. Khalaf, and Prof. dr. Lambalk. Thank you for accepting to be

part of the committee and I am looking forward to our discussion as well.

To all researchers, doctors, nurses and other colleagues from the CVV, Cairo university

hospital-Egypt, Royan institute-Iran, Avicenna institute-Iran, Orient hospital-Syria and Banha

university hospital-Egypt thank you for your contribution to PRIMA study described in this

thesis.

A special thanks to all couples that have participated in studies described in this thesis.

Femke and Miriam; I would like to thank you separately for accepting to be my paranymphs

and stand next to me at this special day. Thank you for all the help with the organization and

for keeping up the motivation.

A special thanks to my family. Words cannot express how grateful I am to my mother, father

brothers and sisters for all of your sacrifices to me. Your prayers were the driving force that

pushed so far. I would also like to thank all my friends who supported me in writing, and

motivated me to strive towards my goal. I dedicate this thesis to the memory of my mother,

whose role in my life was, and remains, immense.

At the end I would like express appreciation to my beloved wife Neveen stood by me all

these years and made them the best years of my life, you have been caring and patient and

loving. Youssef, Leena and Layla, my lovely family, raising you up is the greatest blessing

254

and the sweetest adventure and challenge of my life. May be you will not read this book but I

am sure you will read these few lines to see how much I love you.

255

About the author

The author of this thesis was born on August 6th, 1973 in Giza,

Egypt. He did his Master and M.D of Obstetrics and Gynecology

at Cairo University between 2002 and 2010. In 2008 he started at

the Center of Reproductive Medicine of the Academic Medical

Center as a research fellow on the topic ovarian stimulation under

the supervision of prof. dr F.van der Veen, prof. dr Hesham

Alinany, and dr M.van Wely and dr M. Mochtar.

Currently, he is working as an assistant professor at the department of Obstetrics and

Gynecology at the Faculty of Medicine, Cairo University, Egypt. He is married from Nevin

Abdul-Aziz Gad and has three children, Youssef, Leena and Laila.

pure.uva.nl€¦ · mohamed abdel fattah mahmoud youssef 2016 ovarian stimulation in ivf in...

Documents