| In the assisted reproductive technology (ART), the application of controlled ovarian hyperstimulation (COS) technology greatly improves the in vitro fertilization-embryo transfer (IVF-ET) clinical pregnancy rate. The rate of ovarian hyperstimulation syndrome is improve at the same time. Ovarian hyperstimulation syndrome is a kind of iatrogenic complications after COS treatment, characterized by excessive follicular development, ovarian volume increased significantly, increased vascular permeability, and ascites, pleural effusion, oliguria, electrolyte disorder, hepatic and renal function are damaged, blood concentration and thrombosis, severe and even life-threatened.Owing to gonadotropin releasing hormone antagonist (GnRHant) only competitive combining of pituitary gonadotropin releasing hormone (GnRH) receptor and hindering the effect of endogenous GnRH, the luteinizing hormone (LH) fell by the same time did not affect the pituitary cells of gonadotropin (Gn) of the reserves, so it can be quickly restored to pituitary gonadotropin releasing hormone agonist (GnRHa) reaction, this feature makes the GnRHa instead of hCG become possibly. Synthesis of vascular endothelial growth factor in the human body to promote after injection of hCG, which induced OHSS. While GnRHa induced endogenous LH peak duration, which is shorter than the LH peak duration in a natural cycle or injection of hCG injection of GnRHa can not maintain normal luteal function, lead to irreversible luteolysis, E2 and P levels decreased, that lead to reduce the incidence of OHSS. GnRHa induced oocyte maturation can effectively prevent or eliminate the occurrence of OHSS.GnRHa can induce endogenous LH to induce oocyte final maturation. A study on Daniel Griffin et al. shows that using GnRHa to induce final follicle maturation in the patients who retrieve more than 25% immature oocytes in the last cycle can effectively improve the maturation rate of oocytes, and the previous cycle is the application of hCG induced maturation of follicle and oocyte maturation rate was 38.5% on average, a new cycle of follicle maturation induced by GnRHa finally, the egg the maturation rate was 75% on average, significantly improve the maturation rate of oocytes, in order to improve the clinical outcome of IVF-ET.Compared with the natural cycle and hCG induced follicle maturation, GnRHa induced endogenous LH peak duration is short, generally a peak quickly reached in 4 hours, and then began to decline.The decline wave will last 20 hours. Recently there were cases reports shows, using GnRHa to induce final follicle maturation fail in oocyte retrieval in on one side, application of hCG to save low levels of LH, at the same time, injection of hCG5000IU-10000IU oocytes, oocyte retrieved after 35 hours later after and can successfully get the eggs. Kummer research shows that, application of GnRHa in the antagonist to induced follicular final maturity of the patients, all empty follicle syndrome patients were injected with GnRHa 12 hours after LH is not more than 15mIU/ml and progesterone not more than 3.5ng/ml. Our team previous study shows using single GnRHa to induce final follicle maturation, there are 5.5% patients GnRHal2 hours after LH injection was lower than 15IU/ml, but did not fail in oocyte retrieval. So we assume that the possible reasons to induce follicular, different from the natural cycle of maturation failure is LH peak of endogenous GnRHa induced lower and shorter duration. While the LH peak in natural cycle reach to peak cost 14 hours, the peak lasts 14 hours and then decreased, decreased wave duration 20 hours. Research has shown that, repeated injection of GnRHa can make the LH secretory period extended for more than 14 hours, though it was significantly shorter than in the natural cycle, but for the induction of follicular maturation may be enough. Therefore, we in the GnRH antagonist protocol in the two application of GnRHa induced oocyte maturation, in order to improve the drawbacks of peak value of single application of GnRHa induced endogenous LH peaks is low and short duration.From 2012 March to 2015 February 156 patients were enrolled in the study, all the patients were use GnRH antagonist protocol and employing repeat GnRHa trigger to induced oocyte final maturation of patients. Analysis the infertility patients who use GnRH antagonist protocol and employing repeat GnRHa trigger to induced oocyte final maturation, analysis the changes of ovarian and hormone level in different time, oocyte retrieval rate, the maturation rate, fertilization rate and the influence on the outcome of pregnancy, in order to explore the clinical application of GnRH antagonist protocol and employing repeat GnRHa trigger to induced oocyte final maturation to prevent and reduce the occurrence of OHSS, meanwhile to obtain better clinical outcome.Part I The characteristic of hormone levels and ultrasonographic in the patients who use GnRH antagonist protocol and employing repeat GnRHa trigger to induced oocyte final maturationObjectiveFor the 156 patients who use GnRH antagonist protocol and employing repeat GnRHa trigger to induced oocyte final maturation, analysis of the hormone level and ovarian changes after application of GnRHa, to explore the effects and methods in clinical application of GnRH antagonist protocol and employing repeat GnRHa trigger to induced oocyte final maturation to prevent and reduce the occurrence of OHSS.Materials and MethodsPatients from 2012 March to 2015 February were collected in the Southern Medical University Southern Hospital of Reproductive Center for in vitro fertilization and embryo transfer (IVF-ET)/intracytoplasmic sperm injection (ICSI) application of fertility treatment for GnRH antagonist protocol and employing repeat GnRHa trigger to induced oocyte final maturation in 156 patients. Inclusion criteria: application of the antagonist protocol for controlled ovarian hyperstimulation; age less than 40 years; and with polycystic ovary syndrome (PCOS) or polycystic ovarian morphology (PCOM) patients or once occurred OHSS; employing repeat GnRHa trigger to induced oocyte final maturation. Exclusion criteria:costing cycle; and cycles for oocyte donors.Using GnRH antagonist protocol as controlled ovarian hyperstimulation scheme. When there is more than 2 to 3 dominant follicles that diameter greater than 18mm, and number of the diameter over 10mm follicles more than 18 and,or estrogen is not less than 4000pg/ml in the evening injection of 0.2mg short effect GnRHa, the next day at morning blood check basic follicle stimulating hormone (FSH), luteinizing hormone (LH), progesterone and estrogen, and injected again 0.2mg short effect GnRHa, after the time of first injection of 0.2mg short effect GnRHa of 35 to 36 hours later pick up oocyte by transvaginal ultrasound monitored, according to the criteria of our center for routine IVF or ICSI fertilization and embryo culture,4 to 6 hours after retrieval, granulose cells in the outside layer of oocytes were removed, when the indications for intracytoplasmic sperm injection (ICSI) were fit based on previous or present results of semen, the morphology and the maturity of the oocytes were observed. If there were no ICSI indications. conventional IVF was applied. The fertilization rate of oocytes and the status of embro development were observed and recored. On the third day after oocyte retrieval, the good embryos were chosen to be transferred, and the left were frozed or blastocyst culture, abandoned the poor quality embryos. on the second day of oocytes retrieval, the third day after oocyte retrieval and the seventh day after oocyte retrieval of the patients who cancel the transplant, monitoring of the patients with the change of ovarian size.Analysis of all of 156 patients of the baseline of clinical characteristic in patients with hormone level and ovarian size changes at different times; according to the results of the hormone after 12h of GnRHa trigger, LH was lower than 15mIU/ml and /or progesterone is less than 3.5ng/ml and filling with human chorionic gonadotropin (hCG) 2000IU is divided into additional hCG group, the rest did not add hCG was classified as no additional hCG group, hormone changes of the two groups were compared. All dates were analyzed by SPSS16.0 software, data was expressed by mean±standard deviationsaid. Data were analyzed using One-way ANOVA and chi-square test, as appropriate. Measurement data using analysis of variance, homogeneity of variance using the Welch approximate variance analysis. With a P <0.05 was considered statistically significant.ResultIn the 156 cycles, a total of 115 cycles employ of IVF treatment,30 cycles received ICSI treatment, a total of 11 cycles application of IVF+ICSI. The average age of infertility patients was (29.8±3.7) years, the average body mass index (BMI) is (21.4±2.9) kg/m2, among the patients,one of the main factors of infertility is anovulatory patients accounted for 30.8%(48/156), and PCOM/PCOS of the patients was 60.3%(94/156), bilateral antral follicle count average is (26.3±7.5). And the controlled ovarian hyperstimulation treatment:the gonadotropin (Gn) starting dose of 75IU-225IU, average doseof Gn is(150.5+42.2) IU, days of Gn duration 7-25 days, average (10.1+2) days,the days of duration antagonist average is (5.5+1.4) days, total Gn dose averaged (1586.7+617.4) IU. There were no difference between the additional hCG group and no additional hCG group among age, infertility, basic AFC, and basal hormone,but the BMI in no additional hCG group and additional hCG group were (21.2+2.9) kg/m2 and (23+2.8) kg/m2, respectively, the difference was statistically significant (P< 0.05).After 12 hours injection of 0.2mg GnRHa (post day of trigger)the FSH, LH and E2 average level were(22.6±8.6)IU/ml,(65.8±45.4)IU/ml and(6060.4±2975.0) pg/ml respectively,have reached a peak, and then decreased gradually. And progesterone in the first 24 hours of the injection of GnRHa (post day evening of trigger) have reached a peak and average level was (15.7±10.6) ng/ml. The next morning of trigger in no additional hCG group the average level of LH and P is were (57.3±37.2) mIU/ml VS (30.3±14.2) mlU/ml and (10.7±6.9) ng/ml VS (7.2±3.9) ng/ml respectively.higher than that of additional hCG group, and the difference was statistically significant (P< 0.05),on the trigger day in no additional hCG group the average level of P is also higher than that of additional hCG group,the average level was(1.2±0.6)ng/ml VS(0.8±0.4)ng/ml and the difference was statistically significant (P< 0.05).Bilateral ovarian size reaches the maximum in the second days after oocyte retrieval, the left ovarian average diameter was(56.3.0±7.4) mm and the right ovarian average diameter was (56.8.0±9.1) mm, then the ovaries gradually restored, the patients who cancel transplant will follow-up to 7 days after oocyte retrieval,and find the ovarian size gradually returned to almost normal range. Among the 156 patients, no case of severe OHSS,17 cases (10.9%,17/156) patients developed moderate OHSS.Conclusion1. Use GnRH antagonist protocol and employing repeat GnRHa trigger to induced oocyte final maturation, BMI is negative correlation with LH and P levels;2. Although repeat GnRHa trigger to induced oocyte final maturation cannot induce the second LH peak, but extended the LH peak decreased period, more effective in inducing the mature follicle;3. Using GnRH antagonist protocol and employing repeat GnRHa trigger to induced oocyte final maturation can effectively prevent the occurrence of moderate and severe OHSS, the possible reason is that luteolysis, enlarged ovaries can be recovered in a short period of time and the serum E2 decreased rapidly.Part II Analysis of oocyte, embryo quality and clinical outcome after using GnRH antagonist protocol and employing repeat GnRHa trigger to induced oocyte final maturationObjectiveInvestigation of the oocyte, embryo quality and clinical outcome of the 156 patients who were use GnRH antagonist protocol and employing repeat GnRHa trigger to induced oocyte final maturation, in order to provide basis for clinical application of this protocol is better.Materials and MethodsThe material is the same with the first part. According to whether or not adding hCG divided into no additional hCG group and additional hCG group; according to whether or not LH and progesterone level is more than 15mIU/ml and 3.5ng/ml, no additional hCG group divided into two groups, standard group and non-standard group, endometrial preparation protocols in the frozen thawed embryo transfer(FET) are divided into (1) the natural cycle (NC);(2)hormone replacement therapy cycle (HRT) and (3) controlled ovarian stimulation cycles.12 days after embryo transfer pregnancy test determination, the test positive patients continue to luteal support, embryo transplantation 4 weeks after vaginal ultrasound examination to confirm the clinical pregnancy. Observation indexes:implantation rate of transplantation cycle, clinical pregnancy rate, abortion rate, ongoing pregnancy rate and so on. The statistical approach is the same with the first part.ResultThere were a total of 115 cycles treat with IVF and 30 cycles treat with ICSI therapy, in the IVF and ICSI cycles the normal fertilization rates were 63.5% and 64.4% respectively, the difference was not statistically significant (P>0.05).156 cases of patients who use GnRHa to induced oocyte final maturation, the number of available embryo average is (8.6+4.8), the average number of good quality embryos up to (5.9+4). In the next afternoon after trigger(after GnRHa trigger 18h)the in the no additional hCG group of standard and no standard group, and additional hCG group, for ICSI fertilization is respectively 26 cases,2 cases and 2 cases, among the no additional hCG group, standard group and non-standard group of oocyte retrieval average number were (21.5±8.5) VS (13.7±7.1) VS (18.0±6.1) respectively, average oocyte retrieval rate were 61.2% VS 40.4% VS 52.8% respectively,the average normal fertilizationof with ICSI therapy were 61.5% VS 83.3% VS 86.4% and the average number of discard embryos were (8.5±7.2) VS (5.3±4.6) VS (3.8±3.2) respectively,all of that have significant differences, and the difference was statistically significant (P< 0.05). Oocyte retrieval rate in non standard group were significantly decreased compared with the other two groups, the difference was statistically significant (P< 0.05), non standard group in non standard group was significantly reduced compared with standard group, and the difference was statistically significant (P< 0.05). Normal fertilization rate of ICSI therapy in standard group was 61.5%, than the other two groups were significantly decreased, and the difference was statistically significant (P< 0.05). Discarded embryos in additional hCG group was an average of (3.8+3.2), significantly lower than the standard group (8.5+7.2), and the difference was statistically significant (P< 0.05).156 cases of patients repeat injection of GnRHa to induce oocyte final maturation,60 cases were transferred in fresh embryo transfer cycle, and a total of 115 patients with 178 cycles taken frozen thawed embryo transfer. The clinical pregnancy rate in fresh cycle was 33.3%(20/60),lower than frozen thawed embryo transfer cycle clinical pregnancy which was 55.1%(98/178),the implantation rate in fresh embryo transfer cycle was 22.9%(27/118), lower than that in the frozen thawed embryo transfer cycle which was 38.3%(137/358), and the difference was statistically significant (P< 0.05). Ectopic pregnancy rate increased significantly in the fresh embryo transfer compared with frozen thawed embryo transfer cycle,the rate was 20.0%(4/20) VS 3.1%(3/98), and the difference was statistically significant (P < 0.05). In fresh embryo transfer cycle there were 56 cases taken transferred of no additional hCG group, additional hCG group transplantation in 4 cases.And additional hCG group the pregnancy rate was 50%(2/4),while no additional hCG group the pregnancy rate was 32.1%(18/56), no significant difference (P>0.05). In frozen thawed embryo transfer cycles, non additional hCG group and additional hCG group were respectively 99 cases and 16 cases taken frozen thawed embryo transfer, a total of 147 cycles and 31 cycles respectively. The clinical pregnancy rate, implantation rate and abortion rate in the two groups of patients were 55.8%(82/147) VS 51.6%(16/31),39.7%(117/295) VS 31.7%(20/63) and 11.0%(9/82) VS 18.8% (3/16) respectively,and there were no significant differences between the two group (P>0.05), and the ectopic pregnancy rate in additional hCG group than those no additional hCG group increased significantly,the rate was 12.5%(2/16) and 1.2% (1/82) respectively, and the difference was statistically significant (P< 0.05).Conclusion1. In the GnRH antagonist protocol employing repeat GnRHa trigger can effectively induced oocyte final maturation, retrieval more oocyte. Adding hCG can effectively save the problem that caused by GnRHa induced by endogenous LH deficiency which lead to oocyte maturation rate decreased and oocyte retrieval number cut down.2. For the patients whose LH is no more than 15mIU/ml and/or progesterone no more than 3.5ng/ml after GnRHa triggerl2 hours, adding to hCG can improve oocyte rate, through the elimination of fresh embryo transfer, also can prevent the occurrence of severe OHSS.3. In the GnRH antagonist protocol employing repeat GnRHa trigger can obtain high planting potential embryo. The frozen thawed embryo transfer achieve high clinical pregnancy rate and low ectopic pregnancy rate,that may associated with the protocol affect endometrial receptivity in fresh cycle, so we suggested that we can cancel the fresh transfer cycles, and freezing-all embryo. |
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