GnRH-a and Pregnancy Rate in In Vitro Fertilization (IVF) Cycles.
Condition: Endometriosis; Infertility
MeSH terms: Infertility; Endometriosis
Study type: Interventional

Summary: 
      The investigators attempted to establish a rationale for the Gonadotropin Releasing
      Hormone-agonist (GnRH-a) administration, post-laparoscopically, in women with mild
      endometriosis (until stage II, according to AFS) who underwent IVF-ET procedure. Since GnRH-a
      reduces cytokine's concentration in serum (Iwabe et al., 1998; Iwabe et al., 2003) and
      peritoneal fluid of women with endometriosis (Taketani et al., 1992) the investigators
      hypothesized that GnRH-a can reduces also cytokine's concentration in the follicular fluid
      and this action may improve the oocyte quality and the fertility of these women.
    

Detailed description: 
      This prospective, randomized study with control group was carried out at the Department of
      Obstetrics and Gynecology, Ioannina University School of Medicine (Ioannina, Greece). The
      study population consisted of 120 infertile women (more than a year of sexual attempts), aged
      29-38 years, with laparoscopically documented endometriosis referred to the In Vitro
      Fertilization (IVF) Unit of the Department for infertility treatment during a 7-years period
      (May 2004 to September 2010). In addition, in the current study, we used 60 women with tubal
      infertility, documented by laparoscopy, without prior history of ovarian surgery,
      hydrosalpinx, and/or endometriosis as control group. This group was used to see if
      endometriosis affect the women's fertility. The participant's enrolment was made by three
      following authors A.K., K.Z., and M.P. During laparoscopy, the endoscopist documented the
      extension of the disease, the distribution of endometriotic lesions into the peritoneal
      cavity, and the presence/absence of active endometriotic lesions (red vascularized areas).
      All visible active endometriotic lesions were cauterized with bipolar diathermy. Women with
      sonographic evidence of ovarian endometrioma > 2 cm in mean diameter, with early follicular
      phase serum Follicular Stimulating Hormone (FSH) levels > 12 mIU/ml were excluded from the
      study. Cases of male factor infertility defined as a concentration of motile sperm less than
      10 x 106 /ml and sperm with normal morphology less than 4% (Kruger, strict criteria) were
      also excluded from the study.

      All women who decided to undergo an IVF-Embryo Transfer (ET) attempt were randomized into two
      groups according to administration or not of GnRH-a treatment, post-laparoscopy. The
      randomization is performed by accessing a central internet-based randomization program. The
      random allocation sequence and the assignment of the participants to interventions were made
      by the first author of the study (A.K.). The first group (Group A) was consisted of 60 women
      who received a depot preparation of a GnRH-a, 3.75 mg s.c, (leuprolide, Daronda depot, 3.75,
      Abbott, Hellas) every 28 days for three injections. The investigators preferred to pre-treat
      study patients with a long-acting GnRH-a for a period of 3 months because it has already
      reported that pregnancy rates after IVF-ET are similar in patients with endometriosis who are
      pre-treated with a GnRH-a for 10 to 90 days or greater than 90 days (Caruso 1997; Surrey et
      al., 2002). In this group, laparoscopies were performed 4 to 6 months prior of any cycle
      initiation for infertility. The second group (Group B) was consisted of 60 infertile women
      with endometriosis who did not receive the long-acting GnRH-a. All women were comparable
      regarding mean age, BMI, and duration of infertility.

      All women of control and of group B, underwent controlled ovarian hyperstimulation (COH)
      after down-regulation with a GnRH-a (leuprolide, 20 IU/day, Daronda, 2.8, Abbott, Hellas) in
      a long protocol with a mid-luteal start. Administration of recombinant follicle stimulating
      hormone (rFSH, Gonal-F, Serono, Geneva, Switzeland) was started after at least 14 days of
      leuprolide therapy and when serum estradiol (E2) had been less than 100 pmol/l and when the
      thickness of the endometrium was less than 5mm. Down-regulation in women of group A was
      initiated 30 to 45 days after the third GnRH-a injection. A starting dose of 150 IU of
      follicle stimulating hormone (rFSH, Gonal-F, Serono, Geneva, Switzerland) was adjusted
      individually from day 6 of the cycle according to estradiol (E2) values and ultrasonographic
      follicular measurements. An ovulatory dose of human chorionic gonadotropin (HGG) (Pregnyl,
      Organon, Oss, The Netherlands) 5,000-10,000 IU was administered I.M. when mean diameter of an
      average of two to four follicles was larger than 16mm and the plasma estradiol concentration
      was higher than 1500 pmol/l.

      All women were provided to luteal-phase support with natural micronized progesterone
      (Ultrogestan, Faran, Athens, Greece), 600 mgr daily vaginally in three divided dosages,
      starting the day after embryos transfer.

      Follicular fluid sampling, oocyte collection and IVF Follicular fluid (FF) samples were
      collected during oocyte retrieval. From each patient, follicular fluid was sampled from the
      first one to three mature follicles, having a diameter of 18-20mm. Tumor Necrosis
      Factor(TNF)-a, Interleukine (IL)-1β, IL-6, IL-8 and IL-1-ra were measured in the FF of all
      women (secondary outcome measures). To prevent any cytokine alterations, only blood-free
      samples were used. IVF was performed in all cases. The fertilization rates were estimated for
      every woman 24 hours after oocyte retrieval (primary outcome measure).

      Embryo grading and transfer The embryo quality and the clinical pregnancy rate were also
      primary outcome measures. Embryo development was evaluated 2 days after oocyte pick-up. The
      number of blastomeres and the proportion of embryo volume occupied by fragments were used for
      the evaluation. Embryos with < 10%, < 10-20%, < 20-30% and >30% fragments were estimated as
      grade 1,2,3 and 4, respectively. Three embryos with the highest blastomere number and the
      best morphology were transferred in each cycle. The remaining high-grade embryos were
      cryopreserved the same day.

      Pregnancy was diagnosed by quantitative β-hCG, two weeks after embryos transfer. Clinical
      pregnancy was confirmed by observing fetal cardiac activity on transvaginal ultrasound four
      weeks after a positive pregnancy test. The clinical pregnancy rate and the quality of embryos
      were estimated in all women. The pregnancy rate was defined as the presence of
      sonographically visualized cardiac activity per cycle initiated.
    

Intervention name(s): Leuprolide; IVF
Intervention type(s): Drug; Procedure
Intervention description(s): single injection of 3.75 leuprolide every 28 days, 3 dosages; Assisted Reproduction Technique.
Other intervention name(s): Daronda depot 3.75, Abbott, Hellas
Intervention MeSH terms: Leuprolide
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: cytokines; endometriosis; fertilization rate; follicular fluid; pregnancy rate