MRI follow-up for pancreatic intraductal papillary mucinous neoplasm: an ultrashort versus long protocol

Purpose To evaluate whether an ultrashort-protocol (USP) MRI including only T2-weighted HASTE axial and 3D MRCP SPACE sequences adequately measures the largest diameter of the largest cyst and the main pancreatic duct (MPD) and identifies worrisome features (WF) and high-risk stigmata (HRS) when compared to longer protocols (LP, long protocol; SP, short protocol; S-LP, short or long protocol). We also calculated reductions in costs associated with USP. Methods This retrospective study included 183 IPMN patients. Two radiologists compared two imaging sets (USP versus S-LP) per patient, comparing the mean values of the largest cyst and MPD and agreement regarding the presence or absence of cystic or MPD mural nodules and solid pancreatic tumors. The interobserver agreement for cystic mural nodules and WF/HRS was evaluated, using the Bland-Altman plot and Cohen’s Kappa. Results A total of 112 IPMN patients were evaluated. For detecting cysts or MPD nodules, WF/HRS, and solid pancreatic tumors, USP and S-LP coincided in 94.9%, 99.1%, 92.4%, and 99.1% of cases, respectively. Both USP and S-LP identified all true cystic mural nodules. The mean size of the largest cyst and MPD was 19.48/19.67 mm and 3.24/3.33 mm using USP versus S-LP, while the mean differences for USP versus S-LP were 0.19 mm and 0.08 mm. The USP cost was 39% of LP cost and 77% of SP. Interobserver agreement was moderate to strong. Conclusions For IPMN surveillance, an ultrashort-protocol MRI provides nearly identical information to the more expensive longer protocols. Graphical abstract

Association Between Menstrual Patterns and Adverse Pregnancy Outcomes in Patients With Polycystic Ovary Syndrome

ObjectiveTo investigate the results of in vitro fertilization among polycystic ovary syndrome (PCOS) patients using the long-acting long protocol regarding the relationship between menstrual patterns and adverse pregnancy outcomes.DesignRetrospective cohort study.SettingUniversity-affiliated reproductive medical center.BackgroundThe menstrual patterns of patients with PCOS is considered related to metabolism; however, no study has analyzed the outcome of in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) in patients with PCOS who have different menstrual patterns. This study aimed to observe the outcomes of IVF/ICSI in patients with PCOS with different menstrual patterns who used the long-acting long protocol.MethodsThis was a retrospective analysis in the first cycle of IVF/ICSI at the Reproductive Medicine Center of the First Affiliated Hospital of Zhengzhou University from January 2017 to December 2019. In total, 1834 patients with PCOS were classified into the regular menstruation group (n=214), the oligomenorrhea group (n=1402), and the amenorrhea group (n=218).ResultsPCOS patients who used the long-acting long protocol of IVF/ICSI had similar clinical pregnancy rates and live birth rates despite having different menstrual patterns. The overall incidence of adverse pregnancy outcomes, including abortion, spontaneous preterm birth (sPTB), gestational diabetes(GDM), hypertensive disorder inpregnancy (HDP), and premature rupture of membranes(PROM, was significantly higher in the amenorrhea group than in the regular menstrual and oligomenorrhea groups (25.88% vs. 30.41% vs. 43.69%; P = 0.013). Additionally, the rates of GDM (2.35% vs. 6.10% vs. 13.79%; P=0.015) and macrosomia (5.26% vs. 10.94% vs. 18.39%; P=0.026) in the amenorrhea group were significantly higher than those in the other two groups. Correction for confounding factors showed that menstrual patterns are related to the occurrence of adverse pregnancy outcomes. Amenorrhea is an independent risk factor for adverse pregnancy outcome (OR [odds ratio]: 2.039, 95% CI [confidence interval]: 1.087-3.822), GDM (OR: 5.023, 95% CI: 1.083–23.289), and macrosomia (OR: 4.918, 95% CI: 1.516–15.954).ConclusionsIVF/ICSI can achieve similar pregnancy and live birth rates in PCOS patients with different menstrual patterns. However, the overall incidence of adverse pregnancy outcomes in PCOS patients with amenorrhea is higher than that in patients with regular menstruation or oligomenorrhea.

Effect of recombinant follicular stimulating hormone and human menopausal gonadotrophins on the oocytes number in patients undergoing assisted reproductive technique

<p><strong>Background &amp; Objective:</strong> The data regarding the effectiveness of various protocols used for controlled ovarian stimulation (COS) in assisted reproductive techniques (ART) in our own population is scant. This study compares recombinant follicular stimulating hormone (rFSH) and human menopausal gonadotrophins (HMG) in terms of follicular numbers and oocytes retrieved in Pakistani women undergoing ART.</p> <p><strong>Methods</strong>: A total of 300 patients were selected out of 1,950 patients who visited the hospital for in vitro fertilization/intra cytoplasmic sperm insemination (IVF/ICSI) from June 2018 to December 2020. These patients were further divided into two categories: first category (1) was given long protocol and the second category (2) was given short antagonist protocol. Each category was further sub-divided into two groups; group A who received HMG, and group B who received rFSH for COS.</p> <p><strong>Results: </strong>There was a significantly higher number of follicles and oocytes retrieved in category 1, with rFSH (20.01 &plusmn; 4.91, 15.19 &plusmn; 9.18) versus. HMG (16.07 &plusmn; 5.67, 11.10 &plusmn; 5.07) with a p-value (0.00, 0.004). On the other hand, in category 2, the number of follicles was insignificant (p-value = 0.319) in both groups. Contrary to that the number of oocytes retrieved was significantly higher with a p-value of &le; 0.05 in both groups.</p> <p><strong>Conclusion:</strong> In COS in ART, long protocol with rFSH has much better results both in terms of follicular numbers and retrieved oocytes. While for the short protocol with the antagonist, rFSH has been demonstrated to be superior to HMG but that is limited to the number of oocytes.</p>

Optimum Number of Oocytes Retrieved Among Patients With Polycystic Ovary Syndrome Treated Using The Follicular Phase Long-Acting Long Protocol: A Retrospective Cohort Study

Background: The optimum number of oocytes retrieved by the follicular phase long-acting long protocol is still unknown. This study aimed to analyze the optimum oocyte number in patients with polycystic ovary syndrome (PCOS) undergoing this protocol.Methods: A total of 1816 PCOS patients aged <35 years who were undergoing their first cycle of in vitro fertilization or intracytoplasmic sperm injection (IVF/ICSI) between January 2017 and June 2019 were identified and reviewed. All patients underwent stimulation using a follicular phase long-acting long protocol. In this retrospective cohort study, patients were categorized into seven groups according to the number of oocytes retrieved (group A, 1–5; group B, 6–10; group C, 11–15; group D, 16–20; group E, 21–25; group F, 26–30; group G, >30). The main outcome indicators were the rates of high-quality embryo, fresh cycle pregnancy, cumulative pregnancy, and “freezing all” for high ovarian response. The cumulative pregnancy and “freezing all” rates for high ovarian response were analyzed using multivariate logistic analysis.Results: The high-quality embryo rate decreased with the increase in the number of oocytes retrieved (P<0.001). In the <20 oocyte group, the clinical and cumulative pregnancy rates increased with the number of oocytes retrieved, and the “freezing all” rate for high response was within 30%. In the >20 oocyte group, with an increase in the number of oocytes retrieved, no significant change was found in the clinical and cumulative pregnancy rates (P>0.05); however, the incidence of “freezing all” rate for high response was significantly increased (P<0.001). After correcting for confounding factors, the number of oocytes retrieved was an independent predictor of the “freezing all” rate for high ovarian response (odds ratio [OR], 1.085; 95% confidence interval [CI] 1.057–1.113) and cumulative pregnancy rate (OR 1.091, 95% CI 1.057–1.126). The high-quality embryo rate was significantly affected by the cumulative pregnancy rate (OR, 59.076; 95% CI: 29.591–117.938).Conclusion: In PCOS patients aged <35 years treated using the follicular phase long-acting long protocol, considering clinical outcomes, laboratory indicators, and safety, appropriate ovarian stimulation should be used to control the number of oocytes retrieved at 11–20.

The GnRH Antagonist Protocol is Associated with a Higher Embryo Aneuploidy Rate Than the GnRH Agonist Long Protocol in Chinese Women

Background: Studies in oocytes have suggested increased aneuploidy rates after ovulation induction in mammals and humans. Conversely, some studies have shown that ovarian stimulation does not significantly increase the embryo aneuploidy rate in humans compared with an unstimulated cycle. In addition, the potential effect of the gonadotropin-releasing hormone (GnRH) antagonist (GnRH-ant) protocol and GnRH agonist (GnRH-a) long protocol on embryo aneuploidy remains unknown.Methods: This is the retrospective cohort study from university-affiliated fertility center. In total, 578 early miscarriage patients who conceived through IVF/intracytoplasmic sperm injection (ICSI) after receiving the gonadotropin-releasing hormone (GnRH) antagonist (GnRH-ant) protocol or the GnRH agonist (GnRH-a) long protocol were analyzed to compare the aneuploidy rates in early aborted tissues. In addition, a total of 466 preimplantation genetic testing for aneuploidy (PGT-A) cycles undergoing GnRH-ant protocol or GnRH-a long protocol were also analyzed to compare the aneuploidy rates in embryo.Results: For early miscarriage patients who conceived through IVF/ICSI, compared to the GnRH-a long protocol group, the GnRH-ant protocol group had a significantly higher rate of aneuploidy in early aborted tissues (48.70% vs. 64.52%), and increased aneuploidy was associated with a significantly higher incidence of trisomy 13, 18, and 21 (p<0.01). Regarding PGT-A cycles, compared to the GnRH-a long protocol group, the rate of embryo aneuploidy was also significantly higher in the GnRH-ant protocol group (48.01% vs. 58%). After stratification and multiple linear regression, the GnRH-ant regimen remained significantly associated with an increased risk of aneuploidy in early aborted tissues and embryos [OR (95% CI) 1.767 (1.174, 2.661), OR (95% CI) 1.465 (1.020, 2.102)]. Furthermore, the embryo aneuploidy rate in the GnRH-ant protocol group was significantly higher than that in the GnRH-a long protocol group but only in young and normal ovarian responders [OR (95% CI) 3.54 (1.48, 8.46)].Conclusions: The GnRH-ant protocol is associated with a higher aneuploidy rate in early aborted tissues and embryos than the GnRH-a long protocol in Chinese women. A multicenter, randomized controlled trial would be the optimal strategy to confirm these results.

Hubungan Anti-Mullerian Hormone (AMH) pada Long dan Short Protocol Terhadap Fertilization Rate Pasien In Vitro Fertilization (IVF)

Abstrak Tujuan: Untuk mengevaluasi pengaruh kadar anti-mullerian hormone (AMH) dengan fertilization rate (FR) dan menilai perbedaan pengaruh jenis protokol (long protocol (LP) dan short protocol (SP)) pada tiap tingkat cadangan ovarium terhadap FR pada pasien in vitro fertilization (IVF) dengan Intracytoplasmic Sperm Injection. Metode: Data sekunder dari rekam medis pasien yang menjalani IVF di Aster Fertility Clinic Rumah Sakit Umum Pendidikan dr. Hasan Sadikin pada tahun 2016-2020 dan Bandung Fertility Centre Rumah Sakit Ibu Anak Limijati pada tahun 2018-2019. Penelitian ini analitik observational dengan metode Cohort retrospektif. Hubungan antara dua data kategorik diuji dengan uji chi-square dan uji Kruskal-Wallis digunakan pada data numerik dengan distribusi yang tidak rata pada lebih dari 2 kelompok, Hasil: Hasil data diperoleh nilai rerata kadar AMH secara keseluruhan adalah 3.30 ng/ml dengan rerata capaian FR sebesar 71.97%. Berdasarkan metode IVF yang dipilih, mayoritas pasien menjalani pengobatan SP 54.4% (rerata FR 72.80%) dibandingkan dengan LP 45.6% (rerata FR 70.97%). Tidak ditemukan hubungan yang bermakna antara kadar AMH dengan FR, dinyatakan dengan nilai p=0.977. Kadar AMH terhadap FR bila dipisahkan menurut protokol terapi yang diberikan tidak menunjukkan perbedaan yang bermakna pada masing-masing protokol (LP p=0,763; SP p=0,843). Mengenai hubungan antara protokol IVF dengan FR juga tidak diperoleh perbedaan yang signifikan secara statistik dengan nilai p=0,27 (RR 1.17 (0.62-2.15); CI 95%). Penggobatan menggunakan LP (p=0,770) maupun SP (p=0.845) tidak memberikan pengaruh yang bermakna terhadap FR pada setiap kategori AMH. Kesimpulan: Tidak ada pengaruh kadar AMH dan protokol terapi terhadap FR. Kata kunci : In Vitro Fertilization, Fertilization Rate, Anti-Mullerian Hormone, Protokol Stimulasi Ovarium

Is it necessary to monitor the serum luteinizing hormone(LH) concentration on the human chorionic gonadotropin (HCG) day among young women during the follicular-phase long protocol? ：A retrospective cohort study

Background The normal physiological function of LH requires a certain concentration range, but because of pituitary desensitization, even on the HCG day, endogenous levels of LH are low in the follicular-phase long protocol. So our study aimed to determine whether it is necessary to monitor serum LH concentrations and to determine whether there is an optimal LH range to achieve the desired clinical outcome. Methods A retrospective cohort study included 4503 cycles of in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) units from January 1, 2016, to June 30, 2019, in a single department. The main outcome measures included retrieved eggs, available embryos, live birth rate. Results Divided the LHHCG into five groups: Group A (LH ≤ 0.5), Group B (0.5 IU/L < LH ≤ 1.2 IU/L), Group C (1.2 IU/L < LH ≤ 2.0 IU/L), Group D (2.0 IU/L < LH ≤ 5.0 IU/L), Group E (LH > 5 IU/L). In terms of the numbers of retrieved eggs, embryos, high-quality embryos and diploid fertilized oocytes, an increase of the LHHCG level showed a trend of a gradual decrease. However, there was no significant difference in clinical outcomes among the groups.By adjusting for confounding factors, with an increase in LHHCG, the number of retrieved eggs decreased. Conclusion In the follicular-phase long protocol among young women, monitoring of LHHCG are recommended in the clinical guidelines. What’s more, those who undergo Preimplantation Genetic Testing(PGT) may benefit more when the LH level is controlled within a certain range.

Efficacy of three COS protocols and predictability of AMH and AFC in women with discordant ovarian reserve markers: a retrospective study on 19,239 patients

Background Recent studies have consistently shown that AFC and serum AMH are good predictors of ovarian response and have shown strong correlations. However, it is not unusual for reproductive medicine specialists to encounter discordance between them. This is the first study to investigate the efficacies of the different COS protocols when the AFC and AMH levels are discordant. Based on the association between COS protocols and pregnancy outcomes, we attempt to explain the controversial results and clarify the predictive value of AMH and AFC in this context. Methods 19,239 patients undergoing their first fresh in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles with GnRH antagonist protocols, GnRH-a long protocols or GnRH-a ultra-long protocols between January 1, 2016, and December 31, 2019, were enrolled and then divided into four groups in accordance with the boundaries for the AFC and serum AMH level provided by the Poseidon Classification. Our study was divided into two parts. Firstly, we retrospectively compared the effects of the three COS protocols in patients with discordant AMH and AFC. Multivariate logistic regression models were conducted in a forward manner to exclude the influence of confounding factors. Afterward, to increase comparability between Group 2 (low AMH and normal AFC) and Group 3 (normal AMH and low AFC), propensity score matching (PSM) analysis was performed based on age, BMI, the number of embryos transferred, and COS protocol. IVF intermediate and reproductive outcomes were compared between Group 2 and Group 3. Results For people with low AMH and normal AFC (Group 2), the number of total oocytes, clinical pregnancy rate (CPR), live birth rate (LBR) and cumulative live birth rate (CLBR) were significantly higher in GnRH-a ultra-long protocol compared with GnRH antagonist protocol. In multivariate logistic regression models, significant associations of COS protocol with fresh LBR and CPR were found after adjusting for age, BMI, AFC, AMH and the number of embryos transferred. Whereas, in patients with normal AMH and low AFC (Group 3), the number of total oocytes, CLBR, LBR and CPR were highest in the long GnRH-a protocol although there was no statistically significant difference. After PSM, the results showed that although oocytes yield and available embryos in patients with normal AMH and low AFC were significantly higher, there was no significant difference in reproductive outcomes between Group 2 and Group 3. Conclusions We found that women with normal AFC and low AMH may benefit from the GnRH-a ultra-long protocol. Nevertheless, for women with normal AMH and low AFC, the long GnRH-a protocol seems to be associated with better clinical outcomes. Furthermore, after eliminating the confounding factors including the COS protocol, we found that AMH can only predict the number of oocytes but not the quality of oocytes when there was discordance between AFC and AMH.

Patients With Deep Ovarian Suppression Following GnRH Agonist Long Protocol May Benefit From a Modified GnRH Antagonist Protocol: A Retrospective Cohort Study

ObjectiveTo verify if patients with deep ovarian suppression following gonadotropin releasing hormone (GnRH) agonist long protocol may benefit from a modified GnRH antagonist protocol based on luteinizing hormone (LH) levels.DesignRetrospective cohort study.SettingUniversity-based hospital.Patients110 patients exhibited ultra-low LH levels during ovarian stimulation using GnRH agonist long protocol.Intervention(s)As all the embryos in the first cycle were exhausted without being pregnant, these patients proposed to undergo a second cycle of ovarian stimulation. 74 of them were treated with a modified GnRH antagonist protocol based on LH levels. Other 36 patients were still stimulated following GnRH agonist long protocol.Main Outcome MeasureThe primary outcome was live birth rate (LBR). The second outcomes were biochemical pregnancy rate, clinical pregnancy rate (CPR), ongoing pregnancy rate (OPR) and cancellation rate.ResultsReproductive outcomes were much better in the modified GnRH antagonist protocol. The OPR and LBR were much higher in the GnRH antagonist protocol group than in the GnRH agonist long protocol group [odds ratio (OR) 3.82, 95% confidence interval (CI) 1.47, 10.61, P=0.018; OR 4.33, 95% CI 1.38, 13.60, P=0.008; respectively]. Meanwhile, the cancellation rate was much lower in the GnRH antagonist protocol group (OR 0.13, 95% CI 0.02, 0.72; P=0.014). Mean LH level during stimulation did not have a predictive value on live birth. However, it was independently associated with the occurrence of ongoing pregnancy (OR 2.70, 95% CI 1.25, 5.85; P=0.01). The results of sensitivity analyses were consistent with the data mentioned above. The patients got completely different and excellent clinical outcomes in their second cycles stimulated with the modified GnRH antagonist protocol.ConclusionPatients with deep ovarian suppression following GnRH agonist long protocol may benefit from a modified GnRH antagonist protocol based on LH levels.