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Maksudova Mukhae Mansurovna, Republican Specialized Scientific-Practical Medical Center of Obstetrics and Gynecology, Tashkent E-mail: [email protected]
PROSPECTS OF IVF EFFECTIVENESS IMPROVEMENT FOR PATIENTS OF OLDER REPRODUCTIVE AGE
Abstract: The studies examined the effectiveness of recombinant and urinary-derived gonadotropins use in stimulation cycles using gonadotropin releasing hormone (GnRH) antagonists in women of older reproductive age. Keywords: in vitro fertilization, ovarian stimulation, reproductive age.
tant to research optimization of the examination and preparation of women with endocrine forms of infertility to the use of in vitro fertilization methods to increase their effectiveness.
Study Objective: to study the effectiveness of recombinant and urinary-derived gonadotropins use in stimulation cycles using gonadotropin releasing hormone (GnRH) antagonists in women of older reproductive age.
Materials and methods: The study used the ovarian stimulation protocol with GnRH antagonist. From 2-4 days of the menstrual cycle:
The 1st group of patients (main group) was administered with recombinant FSH-Puregon (Organon, Netherlands) or Gonal-F (Serono, Italy) (Fig. 1).
The 2nd group of patients (comparison group) was administered with urinary FSH-Menopur (Ferring, Germany) (Fig. 2).
The starting dose of gonadotropins in the first and second groups was 150-250 IU and depended on the ovarian reserve, the number of administration days ranged from 6 to 16 in the first group and from 6 to 12 in the second group. The daily dose was corrected according to ultrasound data, depending on the growth of follicles. Ultrasound monitoring was performed on the day of ovarian stimulation occurence, on the 5-6th day of stimulation, and then every other day before the day of the appointment of the ovulatory dose of hCG.
GnRH antagonists: Orgalutran (Merck, USA) or Cetrotide (Serono, Switzerland) were administered subcutaneously in a daily dose of 0.25 mg after leading follicle reached diameter of 13-14 mm. The final follicles maturation trigger, i.e. the ovulatory dose of hCG: Ovitrelle (6.5 thousand IU) (Serono, Switzerland) or Pregnyl (10 thousand IU) (Merck, USA) was prescribed after 3 follicles reach a diameter of more than 17 mm.
All patients were treated with Utrogestan 600 mg/day intravaginally before pregnancy was confirmed or excluded according to the number of the hCG ^-subunit in the blood on the 14th day after embryo transfer. A pregnancy test was considered positive at a |?-hCG level of more than 20 IU/L (biochemical pregnancy). Ultrasound diagnosis of clinical pregnancy was carried out 21 days after embryo transfer, after which further patient treatment plans were determined.
Introduction. Study of married couples infertility showed that in almost half of the cases (44.3-52.7%), the reason of infertility is woman reproductive system diseases; in 6.4-19.4% -the reason is pathologies of man reproductive system; and in more than one third of the cases (34.2-38.7%) infertility is the result of reproductive function pathologies ofboth partners [1; 5]. Age is a major factor in determination of in vitro fertilization (IVF) programs and embryo transfer (ET) effectiveness. It determines the number of obtained oocytes, the transferred embryos quality, and the frequency of assisted pregnancies outcomes. Complex IVF and PE programs significantly improve frequency and quality of pregnancies in patients over the age of 38, and also allow using their entire ovarian reserve. The lack of effective methods for restoring natural human fertility has inspired the development of new assisted reproductive technologies (ART), in particular (IVF), with their effectiveness ranging from 28.5% to 32.5% [2; 3]. In recent years, much attention has been paid to the development of methods aimed at increasing the effectiveness of IVF cycles [3; 4; 5].
Studies of a group of women over 40 years old by A. Fu-jimoto et al. (T. Fujiwara, Y. Osuga, T. Yano, O. Tsutsumi, Y. Taketani) revealed the following results: the birth rate of live-born, healthy newborns was 16% and was found only in age group from 40 to 42 years; no pregnancies occurred in patients over 43 years old. Duration of infertility, the partner age, the age at marriage, records of uterus surgery, and other parameters were statistically insignificant in the studied group. The authors concluded that with low FSH values, normal menstrual cycle, and no medical history of ovarian surgeries in women 40-42 years old, good results can be achieved.
As can be seen from the above, despite the expansive ART introduction, contributing to the conception in almost every third married couple with impaired reproductive function, the issues of increasing the effectiveness of expensive in vitro fertilization and embryo transfer continue to be extremely relevant [2; 3]. The effectiveness of IVF (measured in the frequency of pregnancies occurrence) currently does not exceed 35-40% with about a third of all pregnancies are terminated in the early stages due to unknown causes. This makes it impor-
Results of the study: The duration of ovarian stimulation using recombinant gonadotropins (main group) was significantly higher than that when using urinary-derived gonadotropins (comparison group). For instance, in the main group, the duration of stimulation was 9.3 ± 0.2 days, and in the comparison group - 8.6 ± 0.3 days (p < 0.05). In addition, in the comparison group, the final follicles maturation trigger was introduced earlier than in the main group (10.5 ± 0.3 and 11.4 ± 0.2 day of the menstrual cycle, respectively; p < 0.05).
Table 1. - Parameters of ovarian patients of the examined
Ultrasound monitoring revealed that during gonadotropic stimulation, the number of growing follicles in patients of the main group exceeded the same parameter in the comparison group: 7.5 ± 0.5 and 5.7 ± 0.5, respectively (p < 0.05).
There were no statistically significant differences in the number of oocytes obtained during ovarian puncture, in the total dose of gonadotropins, the frequency of ovarian puncture, and the day of ovarian puncture in patients of the examined groups.
stimulation by gonadotropins in groups (M±m)Parameter
Main Group Comparison Group P
Course dose of gonadotropins, IU 2035.4 ± 93.9 1947.6 ± 131.4
Duration of stimulation, days 9.3 ± 0.2 8.6 ± 0.3 < 0.05
Number of growing follicles 7.5 ± 0.5 5.7 ± 0.5 < 0.05
Introduction day of the final follicles maturation trigger, day of menstruation cycle (DMC) 11.4 ± 0.2 10.5 ± 0.3 < 0.05
Frequency of ovarian puncture,% 97.8 93.8
Day of ovarian puncture, DMC 13.3 ± 0.3 12.8 ± 0.3
Average number of oocytes obtained by ovarian puncture 6.4 ± 0.5 5.6 ± 0.7
Frequency of ovarian punctures with no oocytes obtained,% 7.6 6.3
Frequency of cycle cancellation (lack of follicle growth during gonadotropic stimulation of the ovaries),% 1.1 0
Table 2.- Dependence of ovarian response to gonadotropin stimulation in the IVF / IVF + ICSI protocol on hormone levels and age. (M ± St)
Parameter "Weak response" of the ovaries 4 or more oocytes acquired P
Age, years 38.8 ± 0.5 37.6 ± 0.3 < 0.05
FSH at 2 DMC, nmol/L 7.8 ± 0.4 6.4 ± 0.2 < 0.01
AMH 1.2 ± 0.2 2.2 ± 0.2 < 0.005
Table 2 shows the probability (OR) of obtaining a suf- (OR). It can be seen that the chance to get 4 or more oocytes
ficient ovarian response and the risk of obtaining a "weak" in the main group is slightly higher than in the comparison
ovarian response when punctured in IVF/IVF + ICSI pro- group (OR = 1.35, p < 0.05). tocols in older reproductive age women of the study groups
Table 3.- The probability (OR) of obtaining a certain number of oocytes during puncture in IVF/ IVF+ICSI protocols in older reproductive age women in the studied groups (OR)
Oocytes obtained by puncture Studied Group OR p
Main Comparison
1-3 32 13 - > 0.05
34.8% 41.9%
4+ 60 18 1.35 < 0.05
65.2% 58.1%
On the 14th day after the transfer of the level of beta-hCG in the blood, the biochemical pregnancy occurred in 18 (24%) women of the main group and 9 (32.1%) women of the comparison group. After 1-2 weeks, ultrasound shown the gestational sac in 21.3% (16) women of the main group
and 28.6% (8) women in the comparison group. No statistically significant differences in pregnancy rates between groups were found.
Table 4.- The effectiveness of the treatment per study groups
Pregnancy rates per embryo transfer Main Group Comparison Group Total
Biochemical pregnancy n 18 9 27
% 24 32.1 25.9
Presence of the ovum as shown on ultrasound (coefficient of implantation) n 16 8 24
% 21.3 28.6 23.3
Single delivery n 7 4 11
% 9.3 14.3 10.7
Twin delivery n 1 0 1
% 1.3 0 0.9
Miscarriage (ovum on ultrasound) n 2 0 2
% 12.5 0 8.3
Figure 1 shows the changes of FSH, AMH in the blood pregnancy rate was higher than in the age group of 34-37 and the frequency of pregnancy in women of three age groups. years and in the age group of40-43. It should be noted that in the age group of 37-39 years the
Figure 1. Changes of FSH, AMH in the blood and the frequency of pregnancy in women of three age subgroups
Comprehensive assessment of pregnancy probability in cycles of IVF/ IVF+ICSI in patients of older reproductive age
The method of constructing classification trees has developed a scale for obtaining a total index ofclinical pregnancy in the IVF/IVF+ICSI protocols in women of older reproductive age.
The transitional value was the score of 3, which can be considered as a threshold. Patients with score from 4 to 5 have
the chance of clinical pregnancy increased by 21.8 times compared with patients who have score of 0-3; with a prognostic score of 6-7, the chance increases by 120 times (p < 0.001) compared with patients who have score of 0-3.
For the biochemical pregnancy occurrence in the process of building classification trees, the following scale was developed:
Table 5.- Calculing scale for the total prognostic index of clinical pregnancy occurrence in women of older reproductive age in IVF/IVF+ICSI protocols
Parameter Value Score
1 2 3
Age, years Age > 40 0
Age < 40 1
Artificial abortions in past medical history Yes 0
No 1
Table 6.- Calculating scale for the total prognostic index of biochemical pregnancy occurence in women of older reproductive age in the IVF/IVF + ICSI protocols
1 2 3
Ovarian failure Yes 0
No 1
Unilateral 0
Tubectomy in past medical history No 1
Bilateral 2
> 6.5 0
FSH, IU/L (2 DMC) 4.5-6.5 1
< 4.5 2
Parameter Value Score
Age, years Age > 40 0
Age < 40 1
Artificial abortions in past medical history Yes 0
No 1
Ovarian failure Yes 0
No 1
Chronic adnexitis No 0
Yes 1
Duration of embryo cultivation 2, 4, 5 days 0
3 days 1
FSH >6,5 0
FSH, IU/L (2 DMC) 4.5J 1
FSH<4.5 2
Also, the transitional value of 3 can be considered a threshold. When the score is 4-5, the chance of a biochemical pregnancy increases by 20 times (p < 0.001) compared with patients with score of 0-3; at a score of 6-7, by 159 times compared with patients with 0-3.
Conclusion: In summary, in patients of older reproductive age, IVF protocols are characterized by a high frequency of weak (35.3%) and extremely weak response (33.3%) of the ovaries to gonadotropic stimulation; its efficiency and the quality of in vitro fertilization of oocytes is reduced by the transferred surgical interventions on the organs of the reproductive system (unilateral or bilateral cystectomy by 2 times; unilateral or bilateral tubectomy, myomectomy by 1.5 times); ovarian failure (by 1.5 times), clomiphene-resistance (by 2 times), no history of previous childbirths (by times).
The number of oocytes obtained during ovarian puncture, the quality of fertilization and the development of embryos in vitro have a negative correlation with the basal level of FSH and a positive correlation with the concentration in the blood of the anti-Muller hormone; the blood content of inhibin B correlates with the number of type C embryos on the third day after fertilization.
In patients of older reproductive age, IVF protocols use gonadotropin-releasing hormone antagonists, recombinant FSH medications and urinary-derived gonadotropins have equal efficacy in stimulating the ovaries, fertilizing the oocytes and increasing the frequency of pregnancy.
Compared to protocols with recombinant FSH, IVF protocols with urinary-derived gonadotropins are characterized by a high rate of embryo development (with higher number of blastomeres) (on the 3rd day after fertilization, the morula stage occurs in 17.1% and 6.9% cases, respectively), greater frequency of embryo transfer into the uterine cavity on the 5th day of development (7.6% and 2.2%), cryopreservation at the morula stage (50.0% and 27.9%) and blastocyst stage (18.2% and 1.5%).
In IVF protocols with urinary-derived gonadotropins, LH in blood of the patients on the day of the introduction of the final oocyte maturation trigger is 2 times lower than that in IVF protocols with recombinant FSH and has a high negative relationship with the quality of fertilization and embryo development in vitro.
In IVF protocols with urinary-derived gonadotropins, the duration of ovarian stimulation is shorter when compared
with recombinant FSH. Additionally, the thickness of the endometrium during the transfer of embryos into the uterus with urinary-derived gonadotropins is greater than with the use of recombinant gonadotropins.
In IVF protocols for patients of older reproductive age, the frequency of pregnancy is determined by the calculating scale for the total prognostic index of the of clinical preg-
nancy occurrence in women of older reproductive age in IVF/IVF+ICSI protocols. The transitional value that can be considered as a threshold was score of 3. Score from 4 to 5 increases the chance of clinical pregnancy by 21.8 times compared with patients who have score of 0-3; with a prognostic score of 6-7, the chance of pregnancy increases by 120 times (p < 0.001) compared with patients who have score of 0-3.
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