1

1

Source: The effect of luteal phase gonadotropin-releasing hormone antagonist administration on

2

IVF outcomes in women at risk of OHSS, by Maryam Eftekhar, Sepideh Miraj, and Zahrasadat

3

Mortazavifar used under CC-BY

4

The eEffect of luteal phase gonadotropin-releasing hormone antagonist administration on in5

vitro fertilization IVF outcomes in women at risk of ovarian hyperstimulation syndrome: A

6

retrospective study OHSS

Commented [A1]: Dear Author,
Thank you for this opportunity to assist you on yourmanuscript. I have checked the manuscript for language,
grammar, readability, consistency, and flow, and formatting
per the target journal guidelines(https://journals.plos.org/plosone/s/submission-guidelines).
Please let me know in case you have further queries or
doubts regarding the revisions. Do go through my commentsin the manuscript and in the attached letter for more detailon my work and the changes I have made.
All my best wishes!!
Commented [_2]: The title may be up to 250 characters.
Your current title is well within this limit. I have added thestudy design to the title in line with journal preferences

7
Short title: Luteal phase GnRH antagonist effects on IVF outcomes in women with OHSS risk

Please use this title at all instances going forward.

9

Authors:

Commented [_3]: In general, avoid using abbreviations inmanuscript titles. PLOS One recommends submitting authors
to avoid specialist abbreviations if possible. Therefore, I havespelled out the abbreviations used in this title to adhere to
this instruction.

10

Affiliations:

8

11
12
13
14

*Corresponding Author:

Commented [_4]: As per the guidelines, a short title of up to
100 characters is required. Please check if you agree with mysuggestion.
Commented [_5]: On the title page, write author names in
the following order:•First name (or initials, if used)•Middle name (or initials, if used)•Last name (surname, family name)Author names will be published exactly as they appear in theaccepted manuscript. Indicate affiliations by number only.
Affiliation footnotes should appear in numerical order at firstmention. Please use the symbols provided in this documentfor other designations. Numbers and symbols should be insuperscript.
Commented [_6]: Each author on the list must have an
affiliation. Include each component in order of small to large(Department, Division, Section, Institution, City, State,
Country). • Do not include ZIP or Postal Codes, street
addresses, or building/office numbers. • Do not use
abbreviations (e.g. Dept.). • Do not list positions within an
institution (e.g. Department Chair, Professor, etc.). • List
each affiliation individually and in full.
Commented [_7]: Only one corresponding author can be
designated in the submission system, but this does not
restrict the number of corresponding authors that may belisted on the article in the event of publication. Whoever isdesignated as a corresponding author on the title page ofthe manuscript file will be listed as such upon
publication. Include an email address for each corresponding
author listed on the title page of the manuscript.
Do not include physical addresses; only email addresses are
required.
List corresponding author’s initials in parentheses after theemail address.

2

15

16

Abstract

17

Commented [_8]: The headings have been reformatted per
the following journal guideline:
Use Level 1 heading for all major sections (Abstract,
Introduction, Materials and methods, Results, Discussion,etc.). • Bold type, 18 pt font. • Only use italics and text
formatting where needed (e.g. genus and species names,
genes, etc.). • Headings should be written in sentence case(capitalize only the first word of the heading, the first wordof the subheading, and any proper nouns and genus names).

18

Background: Gonadotropin-releasing hormone (GnRH) plays an essential role s in embryo

19

implantation, invasion of trophoblastic tissue, and steroid synthesis in the placenta. However,20

evidence on the effects of gonadotropin-releasing hormone antagonists on pregnancy outcomes is

21

limited.

Commented [_9]: Please note that the abstract, per theguidelines should be less than 300 words, and should notinclude abbreviations, if possible. The word count is wellwithin 300 words.

22

Objective: The aim of this study was to evaluate the effect of GnRH gonadotropin-releasing hormone

Accordingly, I have removed the abbreviations from theabstract.

23

GnRH antagonist administration during the early implantation period on pregnancy outcomes in early

Since there is no specific guideline regarding the structure of
the abstract, I have retained your original style.

24

implantation period.

25

Materials and Methods: In tThis retrospective study included , 94 infertile women at risk of ovarian

Commented [A10]: I have added a sentence describing the
gap in the current literature with respect to the topic ofstudy. Please consider adding a statement that provides
some background information on GnRH antagonists.

26

hyperstimulation syndrome undergoing gonadotropin-releasing hormone GnRH antagonist protocol

27

who were at risk of ovarian hyperstimulation syndrome (OHSS) were included. Sixty-seven patients

28(group I) received Cetrorelix 0.25 mg/daily in the luteal phaseduring the luteal phase for 3 days, while29

in 27 participantpatients (group II) did not receive it, it was not administered. Pregnancy outcomes30

were assessed based on chemical and clinical pregnancy rates.

Commented [_11]: Consider adding a sentence on thestatistical tests used to analyze data.

31

Results: The pregnancy outcomes were not significantly different between the two groups (p=0.224).

32

Conclusion: Thise present study proposed that luteal phase gonadotropin-releasing hormone GnRH

33

antagonist administration during the luteal phase does not affectinfluence the chanceprobability ofCommented [_12]: Please consider providing more details
regarding the critical results of the study. This might beconsidered a little too abrupt and readers may not want toread the entire study if they get the impression that this was
the only point worth noting. Patient mean age andimplantation rates can be mentioned, for example.

34

successful pregnancy outcomes.

35
36

Key Words: Gonadotropin-releasing hormone antagonist, Pregnancy outcome, In vitro fertilization

37
38

Introduction

Commented [A13]: Chemical and clinical pregnancies aredifferent concepts; thus, ideally two p values should be
provided to indicate that there was no significant difference.
Commented [A14]: The conclusion of the abstract shouldrefer only to the tested Cetrorelix, and not to GnRH
antagonists in general. There are several GnRH antagonists
such as Elagolix, Degarelix, but these have not been studied
here.
Commented [A15]: Please considering discussing theimplications and applications of these findings in the clinicalfield at large.
Commented [_16]: There is no specific guideline regarding
the key words. Pease verify with the journal whether these
are required and remove them if not required.

3

39

Female genital tissues organs like such as the ovariesy, endometrium, and placenta are extra extra-

40

pituitary tissues which that express Ggonadotropin-releasing hormone (GnRH) receptors ([1)]. GnRH

41

plays essential roles in embryo implantation, invasion of trophoblastic tissue, and steroid synthesis in42

the placenta [(2)]. There are lLimited evidences evidence is available regarding of the effects of43

GnRH antagonists’ effects on pregnancy outcomes.

44

Several protocols such as GnRH antagonist protocol were have been used for in vitro fertilization

45(IVF) [(3, 4]). Previous studies have evaluated the role of GnRH antagonists in women with poor

46

response to ovulation stimulation. Some studies have were demonstrated GnRH antagonists is to be

47

comparable withto GnRH agonists [(5, 6)]. The most important GnRH antagonist benefits are48

includinginclude: decrease the reduced need ofrequirement for exogenous gonadotropin, shorter time

Commented [_21]: Avoid beginning sentences and clauses
with the overly general “There is,” “There are,” or “There
were” in academic writing. These are just empty filler words.

49

for stimulation, and a cost- effective protocol ([3, 4, 7-9)].

Commented [A22]: A new paragraph has been started here
for better flow.

50

Also Further, GnRH antagonists causes the regression of established severe ovarian hyper stimulation

Commented [_23]: Were these comparable in terms of theireffects? Please provide the missing information.

51

syndrome (OHSS) by luteolysis as a the key mechanism in the prevention of OHSS [(2]). After The

Commented [_24]: It may be a good idea to explain this term
and its application briefly for the benefit of the readers.

52

introductioni of GnRH antagonists into in clinical practice led to , it reduced OHSS rates in

53

IVF/intracytoplasmic sperm injection (ICSI) cycles [(9)]. GnRH antagonists can alleviateimprove the54

poor responses to ovulation stimulation ([6, 10, 11)]. Although Mmany mstudies showed have55

reported the benefits of GnRH antagonists on IVF/ICSI cycle outcomes; however, but theirits effect56

is remains controversial. The use of GnRH antagonists is generally limited to the last few days of57

ovulation in IVF/ICSI cycles.

58

The aim of this study was to evaluate the effects of GnRH antagonist administration effects at

59

pharmacological doses given in during the early implantation period on pregnancy outcomes.

60

Materials and Methods

Commented [_28]: In academic writing, it is customary toprovide an expansion of the abbreviation when first used. I
have provided the expansion here.

61

In this retrospective study, medical records of 94 women that who were at risk of OHSS in IVF/ICSI

62

cycles and has been were refferred to the Research and Clinical Center for Infertility, Yazd, Iran,

Commented [A29]: The research rationale needs to bebetter formulated. In lines 45-48, you report the benefits of
GnRH antagonists on IVF/ICSI cycles outcomes. You thenstate that the effects remain controversial. Where does ...
the[3]

63

between October 2014 and February 2015 were reviewed. The study protocol was approved by theCommented [_17]: In academic writing, ideas need to beconveyed using formal language. I have revised this term to abetter academic term alternative.
Commented [_18]: In American English, the pronoun 'which'is usually used to introduce nonessential information, andthe pronoun 'that' is used to include essential information.
For example, 'The windows, which have red crosses, aresealed' implies that the windows are sealed, and they
incidentally have red crosses. However, 'The windows thathave red crosses are sealed' implies that only the windows
with red crosses are sealed.
Commented [_19]: Intext citations have been reformatted
per the preferred journal style.
Commented [A20]: Please consider adding a sentence or
two providing background information on GnRH antagonists
before talking about the limited evidence on their effects on
pregnancy.

Commented [A25]: While comparing GnRH agonists andantagonists in the Introduction, it would be good to include acomprehensive reference, such as a meta-analysis:
https://pubmed.ncbi.nlm.nih.gov/28903472/;
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0109133;
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0106854
Commented [_26]: A compound adjective is formed by twowords that jointly describe a noun (e.g., 'water' and 'soluble'
in 'water-soluble compound'). Such compound adjectives areusually hyphenated to indicate that they form a single unit.
The use of the hyphen also aids clarity. For example, in thesentence 'I saw a man-eating alligator,' it is clear that the... [1]Commented [_27]: I suggest moving this part of the text toafter the second reference citation in the previous paragraphfor better flow. Please let me know if you agree with thischange, and we can do it for you.
... [2]

Commented [A30]: Please clearly state the novelty of thestudy. Have no previous studies studied the effects of GnRH
antagonist administration during the early implantation
period on pregnancy outcomes.

464

ethics committee of the Research and Clinical Center for Infertility, Yazd, Iran, and oral consent was

65

obtained from all participantpatients.

66

Inclusion criteria were women age <under 40 years old, having more than 20 follicles (>14 mm) at

67

triggering time, and on being at risk of OHSS during the ICSI-IVF/ICSI cycle with embryo transfer.

68

Women with a history of endometriosis, history of or more than 2two implantation failures, and those69

with severe male factor infertility were excluded.

70

TotallyOverall, 94 eligible women were studied in two groups. All participantpatients were treated71with the GnRH antagonist protocol. Patients received recombinant human follicle- stimulating72

hormone (Gonal-F) (150 IU, subcutaneously) for 5 days. Serial transvaginal-vaginal sonography was73

performed. When the a mature follicle (≥14 mm) was detected, GnRH antagonist (Cetrorelix

74(Cetrotide) (0.25 mg/daily, subcutaneously) was injected subcutaneously. Triggering was started

75

initiated with 1500 IU hCG (Pregnyl, Organon, Netherland) and 0.2 mg GnRH-a (Decapeptyl®, ®; 0.176mg)) ( subcutaneously) injection when at least two follicles with a mean diameter of 17 mm was were77

observed.

78

Trans-vaginalTransvaginal egg retrieval was performed egg retrieval was done under sedation after

79

36 hrshours. Sixty-seven67 women received 25 mg CetrorelixCetrotide subcutaneously for 3 days

80

from the day of oocyte retrieval (case group) and 27 participantpatients did not receive

81

CetrorelixCetrotide in luteal phaseduring the luteal phase (control group). 2Two embryos were82

transferred 48 hours after oocyte retrieval using an embryo transfer Labotect catheter (Labotect

83

Gmbh. Lbabor-Technik-Göttingen GmbH, GöttingenGottingen, Germany) In in all patients. All

84transferred embryos were in grade A and B. Progesterone suppositories (Cyclogest®), 400 mg twice85

in a day, was were used vaginally on the day of oocyte collection for luteal phase support, and it

86

continued until the fetal heart activity was documented viaby ultrasonography. Serum beta-hCG (β-87hCG) levels wasere assessed on day 14 after embryo transfer.

88

PA positive pregnancy test was define defined as β-hCG levels >50 IU/L. Pregnancy outcomes were89

assessed based on clinical pregnancy rates (observation of fetal heart activity onby transvaginal

Commented [_31]: Please mention the approval number
here, if available.
As per the guidelines, All research involving human patients
must have been approved by the authors’ Institutional
Review Board (IRB) or by equivalent ethics committee(s), andmust have been conducted according to the principles
expressed in the Declaration of Helsinki.
You may mention this specifically.
Commented [_32]: Please verify if this was only oral, or
written consent was also taken.
Further, per the guidelines,
Subjects must have been properly instructed and haveindicated that they consent to participate by signing theappropriate informed consent paperwork. Authors may be
asked to submit a blank, sample copy of a subject consent
form. If consent was verbal instead of written, or if consent
could not be obtained, the authors must explain the reason
in the manuscript, and the use of verbal consent or the lackof consent must have been approved by the IRB or ethics
committee.
Commented [_33]: When expressing numbers (both cardinaland ordinal) within your text, write numbers one throughnine alphabetically and write numbers 10 and above
numerically, except when the numerals indicate time periods
or are followed by units of measurement.
Commented [_34]: For academic writing, the product name,model number, manufacturer, and country should be
mentioned within the parenthesis. Please provide themissing information.
Commented [_35]: The missing information should be
inserted here as well.
Commented [_36]: Does this apply for both hCG and GnRHa? I have assumed this and removed the parentheses. If only
applicable for GnRH-a, this can be added within the previous
set of parentheses as (Decapeptyl, 0.1 mg, subcutaneousadministration)
Commented [_37]: Starting a sentence, title, or heading witha numeral is considered slightly informal in academic writing
and should be avoided. You could either reconstruct thesentence such that you do not have to start the sentencewith a number or you could spell out the numeral.
Avoid: “20 college students participated in this study.”
Better: “Twenty college students participated in this study”
OR “The participants were 20 college students.”

5

90

ultrasonography 2-3 weeks after positive β-hCG). Implantation rate was defined as the ratio of the91

number of gestational sacs to the number of embryos transferred.

92

Statistical analysis

Commented [_39]: Please note that I made this formattingchange to clearly identify different levels of headings.

93

All of statistical analysies were was done performed by using SPSS 20 (SPSS, Chicago, IL). The

Level 2 Heading • Use Level 2 headings for sub-sections ofmajor sections. • Bold type, 16 pt font. • Only use italics andtext formatting where needed. • Use sentence case.

94

normal distribution of data was checked. Mean±SD values were calculated for descriptive analysis.

95

The Iindependent t-test and χ2 test were used. The level of statistical significances considered aswas

96

set at 0.05. According with to the power analysis, the power of the study was 0.8 and α was 0.05.

97

Results

98

The mean age of participantpatients was 28.56±4.03 years in the case group and 28.03±4.8 years in99

the control group. Basic characteristics of participantpatients in the groups are shown summarized in100

Table 1 table I. There were not No statisticalsignificant ly differences were noted in age, ; duration of101

infertility, ; and basal serum follicle-stimulating hormoneFSH serum, progesterone, and estradiol

102levels in on the day of HCG triggering between the groups. While However, the mean number of103

embryos was different between the groups (Table 1) (Table I). The pregnancy outcome was not

104

significantly different between case and control group (p=0.224). The implantation rate was 14.39%

105

in case group and 9.25% in controls (p=0.089) (Table II).

Commented [_38]: Are you referring to confirmation of apositive pregnancy or β-hCG levels >50 IU/L? If so, I
recommend phrasing in either of these ways for clarity. Else,“test results” can be added after “positive β-hCG.”

Commented [A40]: While discussing the power analysis, you
should also mention the adequacy of the sample size,
stemming from the analysis itself.

Commented [_41]: Commas are typically used to separate
elements in a series (e.g., “I’ve visited Japan, the UK, andEgypt"), but semicolons are used if the elements themselvescontain commas (e.g., “I’ve visited Japan, Thailand, andChina in Asia; the UK, Belgium, and France in Europe; andEgypt, Morocco, and Kenya in Africa").
Commented [_42]: Was this significantly different? If so,please mention the p-value.

106
107

I

108

The basic Data are presented as mean±SD. *Independent Students’Testin s IITable 1: I

109

Baseline characteristics of patients in the two groups

Commented [_43]: As per the guidelines, the tables areinserted immediately after the first paragraph in which they
are cited. Hence, I have moved them from the end of themanuscript to within the manuscript close to where they are
first cited.
Commented [_44]: I made this change per the preferredjournal style.

6

Variables

Case group (n=67) Control group (n=27) p-value *Age (years)

28.56 ± 4.03

28.03 ± 4.8

0.593

3rd dDay 3 FSH level

5.76 ± 2.73

5.71 ± 3.42

0.942

Infertility duration (years)

6.73 ± 3.85

6.66 ± 4.49

0.942

Serum progesterone** (ng/ml)

1.09 ± 0.55

1.11 ± 0.55

0.924

Serum estradiol** (pg/mL)

3337.07 ± 514.44

3301.63 ± 459.04

0.756

110

Data are presented as mean±SD.

111*Independent Students’s t-test.

112** on the day of HCG triggering

113
114

The pregnancy outcome was not significantly different between the groups (p=0.224). The

115

implantation rate was 14.39% in the case group and 9.25% in the control group (p=0.089) (Table 2).

116
117
118
119

Table 2II

Commented [A45]: The journal guidelines do not mention
anything about the use of abbreviations in tables. Pleaseconfirm with the journal whether abbreviations used only
once should outright avoided in the tables or whether
abbreviations should be defined below each respective
table.
Commented [_46]: Please mention the measuring unit forthis metric.

Commented [_47]: Use “in” to refer to a general, longer
period of time, such as months, years, decades, or centuries.
For example, we say “in April,” “in 2015” or “in the 21st
century.” When referring to shorter, more specific periods oftime, use “on” to talk about particular days, dates, andholidays, for example, “I went to work on Monday” or “Let’s
have a picnic on Memorial Day.” For the most specific times,
use “at,” for example, “Meet me at midnight,” or “Theflowers are in bloom at Easter time.”

7

120

ART outcomes in the two studied study groups

Commented [_48]: Please provide the expanded form forthis abbreviation after confirming the guidelines on
abbreviation use in tables.

Case group (n=67) Control group (n=27) p-value *Number of oocytes a

19.86 ± 4.94

18.51 ± 2.84

0.023

Number of embryos a

6.31 ± 5.21

5.22 ± 4.06

0.332

Clinical pregnancy rate b

19 (28.78%)

5 (18.51%)

0.224

14.39%

9.25%

0.089

Implantation rate

121

a

122

b

Data are presented as mean±SD.
: Data are presented as n (%).

123
124

* χ2 test

125
126

127

128

Discussion

8

129

Our results showed indicated that luteal phase GnRH antagonist administration during the luteal phase130

administration did not influenceaffect the chanceprobability of pregnancy. The clinical pregnancy rate131

in studied groups was not significantly different between the study groups. Triggering of final oocyte

132

maturation by hCG induces massive luteinization, increase in the secretion of angiogenic factors

133

secretion (such as angiotensin II, interleukins, vascular endothelial growth factor, histamine, prolactin,

134

prostaglandins, endothelin-1, and selectins) from the corpus luteums luteum of hyperstimulated

135

ovaries,. It leads to development of OHSS by due to increase in vascular permeability, and finally,136

fluid shift to the third space ([12-15]).

137

Previous studies have reported that GnRH antagonist administration in the luteal phaseduring the138

luteal phase improvesd severe OHSS within two 2 days after of the injection of GnRH antagonist by

139

decreasing the ovarian volume, hematocrit, ascites, and oestradiolestradiol and progesterone

140

concentrations [(3, 4, 8]). It These findings suggest s a luteolytic effect of the GnRH antagonist that141

leads d to a decrease of reduced ovarian activity and secretion of angiogenic factors secretion,

142

resulting in regression of severe OHSS [(4, 8)]. “GnRH antagonist inhibits Mmatrix metalloproteinase143(MMP) and therefore can, therefore, disrupt embryo the implantation. GnRH antagonist effect on

144

affects the expression of HOXA10 genes in the endometrium, which is an important regulator of

145

endometrial receptivity” ([16]).

146

GnRH antagonist administration during the peri-implantation period may cause some concerns about147

regarding their potential adverse effects of GnRH antagonist on embryo implantation , and pregnancy

148

and neonatal outcomes ([11]). Our findings showed revealed that the pregnancy rate is was similar

149

between the two studied study groups. There are A few studies have aboutreported on the effect of150

luteal phase GnRH antagonist administration during the administration luteal phase on pregnancy

151

outcomes ([8, 11, 12]). Lainas et al. , in a prospective cohort study on 192 IVF patients who were at152

risk of OHSS, showed reported that pregnancy and neonatal outcomes did not decrease after luteal

153

GnRH antagonist administration during the luteal phase administration ([1]). Some recent studies

154

have documented that GnRhH antagonist administration is not associated with pregnancy or155congenital adverse effects ([1-4, 8-11, 17-20])).

Commented [_49]: The original had an awkward andrather long noun string. As its name suggests, noun strings
are strings containing several nouns in a single sentence,placed one after the other. This makes it difficult tocomprehend the information. It is better to break thisstring down and rephrase the text in a way that improvesclarity and enhances understanding. Please check mychanges in this regard made here.

Commented [_50]: Some conventions differ between British
and American writing. One of these differences can be foundin the spelling of certain words. For example, “flavor” inAmerican English is spelt as “flavour” in British English. Someother examples are
American English: color
British English: colour
American English: anemia
British English: anaemia
It’s always a good idea to refer to a dictionary to find themost suitable spelling for your document. You can refer to
Merriam Webster’s for American English and Oxford
Dictionary for British English, among others.
Commented [_51]: The original idea was incomplete. Please
review my addition.
Commented [_52]: The original statement appeared
incomplete as the effect was not described as such. I haverephrased the sentence to ensure completeness of the idea
presented. Please review.
Commented [_53]: Even when the original study is cited,
quoting directly from a previous study is discouraged. I have,thus, edited the statements for grammar and clarity andremoved the quotation marks.

Commented [_54]: Do you mean “successful/positive
pregnancy and neonatal outcomes”? Alternatively, do you
mean “pregnancy and neonatal outcomes did not worsen”?
Commented [_55]: Twenty references have been citedconsecutively in the manuscript.
Commented [_56]: Since several comparable studies arecited, it may be a good idea to elaborate on their findings
with respect to those of this study. Were the findings exactly
the same? In what ways were these different from thecurrent study?

9

156

This study has some limitations. First, As our study limitations, OHSS evolution and , neonate

157

outcomes in neonates and children outcomes were not studied. Furthermore, Also the follow follow-

158

up period was very short.

159

Conclusion

160

In conclusion, luteal phase GnRH antagonist administration during the luteal phase does not

Commented [A58]: As flagged in the abstract, yourconclusions should be restricted to the antagonist studied.

161

affectinfluence the chanceprobability of pregnancy after assisted reproductive technologyART. The

162

incidence of chemical and clinical pregnancy in groups was not significantly different among patients

Commented [59]: This abbreviation has been only used oncein the main text. Per the guidelines, I have replaced thisabbreviation with its expanded form.

163

who received GnRH antagonist during the luteal phase and those who did not receive it.

164

Acknowledgements

165

This study was supported by Yazd Research and Clinical Center for Infertility, Shahid Sadoughi

166

University of Medical Sciences, Yazd, Iran.

167

Conflicts of Interest

168

The authors declare that there were no conflicts of interests regarding the publication of this article.

169

References

170

1. Lainas GT, Kolibianakis EM, Sfontouris IA, Zorzovilis IZ, Petsas GK, Tarlatzi TB, et al.

171

Outpatient management of severe early OHSS by administration of GnRH antagonist in the luteal

172

phaseduring the luteal phase: an observational cohort study. Reprod Biol Endocrinol. 2012;10: 69-71–

173

71.

174

2. Lainas G, Kolibianakis E, Sfontouris I, Zorzovilis I, Petsas G, Lainas T, et al. Pregnancy and175

neonatal outcomes following luteal GnRH antagonist administration in patients with severe early

176

OHSS. Hum Reprod. 2013;28: 1929–-1942.

Commented [_57]: There is a potential to improve thissubsection of the discussion section. All elements of thelimitations need to be highlighted, including the measurestaken, if any, to avoid those limitations, and ideas stemmingfrom the limitations for future studies.

Commented [A60]: Please considering discussing theimplications and applications of these findings in the clinicalfield at large.

Commented [_61]: This section is not required by the journaland may be deleted. The competing interests need to beprovided via the submission system and should not be
included in the manuscript.
Commented [_62]: Please note that there are conflicting
instructions in the guidelines for reference formatting.
Examples of the format to be followed for references areprovided on the journal page, and the instructions alsomention that the journal follows the style outlined in the
ICMJE sample references. These follow a slightly different
style from that followed by the references on the journal
page. I have followed the following instruction on the mainjournal formatting guidelines page:
Hou WR, Hou YL, Wu GF, Song Y, Su XL, Sun B, et al. cDNA,
genomic sequence cloning and overexpression of ribosomal
protein gene L9 (rpL9) of the giant panda (Ailuropoda
melanoleuca). Genet Mol Res. 2011;10: 1576-1588.
Devaraju P, Gulati R, Antony PT, Mithun CB, Negi VS.
Susceptibility to SLE in South Indian Tamils may be
influenced by genetic selection pressure on TLR2 and TLR9
genes. Mol Immunol. 2014 Nov 22. pii: S01615890(14)00313-7. doi: 10.1016/j.molimm.2014.11.005.
Note: A DOI number for the full-text article is acceptable as
an alternative to or in addition to traditional volume andpage numbers. When providing a DOI, adhere to the format
in the example above with both the label and full DOI
included at the end of the reference (doi:
10.1016/j.molimm.2014.11.005). Do not provide a shortened
DOI or the URL.
Commented [_63]: The citation in PubMed lists the page
number as just 69. Please check this.

10

177

3. Lainas T, Sfontouris I, Zorzovilis I, Petsas G, Lainas G, Kolibianakis E. Management of severe

178

early ovarian hyperstimulation syndrome by re-initiation of GnRH antagonist. Reprod Biomed

179

Online. 2007;15: 408–-412.

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4. Lainas TG, Sfontouris I, Zorzovilis I, Petsas G, Lainas G, Iliadis G, et al. Management of severe

181

OHSS using GnRH antagonist and blastocyst cryopreservation in PCOS patients treated with long182

protocol. Reprod Biomed Online. 2009;18: 15–-20.

183

5. Al-Inany H, Aboulghar M. GnRH antagonist in assisted reproduction: a Cochrane review. Hum

184

Reprod. 2002;17: 874–-885.

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6. Engmann L, DiLuigi A, Schmidt D, Nulsen J, Maier D, Benadiva C. The use of gonadotropin-

186

releasing hormone (GnRH) agonist to induce oocyte maturation after cotreatment with GnRH

187

antagonist in high-risk patients undergoing in vitro fertilization prevents the risk of ovarian

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hyperstimulation syndrome: a prospective randomized controlled study. Fertil Steril. 2008;89: 84–-

189

91.

190

7. Klemmt PAB, Liu F, Carver JG, Jones C, Brosi D, Adamson J, et al. Effects of gonadotrophin

191

releasing hormone analogues on human endometrial stromal cells and embryo invasion in vitro. Hum

192

Reprod. 2009;24: 2187–-2192.

193

8. Lainas TG, Sfontouris I, Zorzovilis I, Petsas G, Lainas G, Alexopoulou E, et al. Live births after

194

management of severe OHSS by GnRH antagonist administration in the luteal phase Reprod Biomed

195

Online. 2009;19: 789–-795.

196

9. Olivennes F, Alvarez S, Bouchard P, Fanchin R, Salat-Baroux J, Frydman R. The use of a GnRH

197

antagonist (Cetrorelix) in a single dose protocol in IVF-embryo transfer: a dose finding study of 3

198

versus 2 mg. Hum Reprod. 1998;13: 2411–-2414.

199

10. Boerrigter PJ, de Bie JJ, Mannaerts BMJL, van Leeuwen BP, Passier-Timmermans DPJ.

200

Obstetrical and neonatal outcome after controlled ovarian stimulation for IVF using the GnRH

201

antagonist ganirelix. Hum Reprod. 2002;17: 2027–-2034.

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202

11. Bosch E, Valencia I, Escudero E, Crespo J, Simón C, Remohí J, et al. Premature luteinization

203

during gonadotropin-releasing hormone antagonist cycles and its relationship with in vitro fertilization

204

outcome. Fertil Steril. 2003;80: 1444–-1449.

205

12. Pellicer A, Albert C, Mercader A, Bonilla-Musoles F, Remohí J, Simón C. The pathogenesis of206

ovarian hyperstimulation syndrome: in vivo studies investigating the role of interleukin-1β,207interleukin-6, and vascular endothelial growth factor. Fertil Steril. 1999;71: 482–-489.

208

13. Gómez R, Soares SR, Busso C, Garcia-Velasco JA, Simón C, Pellicer A. , editors Physiology and209

pathology of ovarian hyperstimulation syndrome. Semin Reprod Med. 2010;28: 448–-457.

210

14. Rizk B, Aboulghar M, Smitz J, Ron-El R. The role of vascular endothelial growth factor and211

interleukins in the pathogenesis of severe ovarian hyperstimulation syndrome. Hum Reprod

212

Update. 1997;3: 255–-266.

213

15. Soares SR, Gómez R, Simón C, García-Velasco JA, Pellicer A. Targeting the vascular endothelial214

growth factor system to prevent ovarian hyperstimulation syndrome. Hum Reprod Update. 2008;14:215

321–-333.

216

16. Eftekhar M, Firouzabadi RD, Karimi H, Rahmani E. Outcome of cryopreserved-thawed embryo

217transfer in the GnRH agonist versus antagonist protocol. Iran J Reprod Med. 2012;10: 297.

218

17. Bonduelle M, Oberyé J, Mannaerts B, Devroey P. Large prospective, pregnancy and infant219

follow-up trial assures the health of 1000 fetuses conceived after treatment with the GnRH antagonist

220

ganirelix during controlled ovarian stimulation. Hum Reprod. 2010;25: 1433–-1440.

221

18. Bonilla-Musoles F, Raga F, Castillo J, Sanz M, Dolz M, Osborne N. High doses of GnRH

222

antagonists are efficient in the management of severe ovarian hyperstimulation syndrome. Clin Exp

223

Obstet Gynecol. 20092008;36: 78–-81.

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19. Siler-Khodr T, Khodr G, Rhode J, Vickery B, Nestor JJ Jr. Gestational age-related inhibition of

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placental hCG, αchalpha hCG and steroid hormone release in vitro by a GnRH

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antagonist. Placenta. 1987;8: 1–-14.

Commented [_64]: Please review this revision. I made thisper the citation available in PubMed. Please let me know if
this is not the correct reference.

Commented [_65]: I made this revision per the citation on
PubMed. Please confirm that it is accurate.

Commented [_66]: Changes were made to this reference per
the available citation on PubMed. Please verify this change.

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20. Ubaldi F, Camus M, Smitz J, Bennink HC, Van Steirteghem A, Devroey P. Premature228

luteinization in in vitro fertilization cycles using gonadotropin-releasing hormone agonist (GnRH-a)229

and recombinant follicle-stimulating hormone (FSH) and GnRH-a and urinary FSH. Fertil

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Steril. 1996;66: 275–-280.

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TablesCommented [_67]: •As per the guidelines, the tables areinserted immediately after the first paragraph in which
they are cited. Hence, I have moved them from the end of
the manuscript to within the manuscript close to where
they are first cited.
•

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Page 3: [1] Commented [_26]

Author

17/08/2021 08:35:00

A compound adjective is formed by two words that jointly describe a noun (e.g., 'water' and 'soluble' in 'watersoluble compound'). Such compound adjectives are usually hyphenated to indicate that they form a single
unit. The use of the hyphen also aids clarity. For example, in the sentence 'I saw a man-eating alligator,' it isclear that the alligator eats humans. Without the hyphen, the sentence will read as 'I saw a man eating
alligator' (i.e., the man was eating an alligator).
Here, “cost effective” is the compound adjective to the noun “protocol”; therefore, it needs to be hyphenated.
Page 3: [2] Commented [_27]

Author

16/08/2021 12:12:00

I suggest moving this part of the text to after the second reference citation in the previous paragraph forbetter flow. Please let me know if you agree with this change, and we can do it for you.

Please note that the reference number order will change if this change is made.
Page 3: [3] Commented [A29]

Author

20/08/2021 19:22:00

The research rationale needs to be better formulated. In lines 45-48, you report the benefits of GnRH
antagonists on IVF/ICSI cycles outcomes. You then state that the effects remain controversial. Where does thecontroversy reside? Could you cite reports with opposing results to those of the studies cited in lines 45-48?