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Excerpt
Two hundred twenty-five patients initiating 292 IVF cycles between January 1993 and December 1994 at the George Washington University Medical Center and the Shady Grove Fertility Center were studied. Analysis was limited to those patients who underwent the same stimulation protocols at both centers using pituitary suppression with a GnRH-a and subsequent ovarian stimulation with hMG. All patients received 0.5 mg/day S.C. injections of leuprolide acetate (LA) beginning in the midluteal phase of the menstrual cycle. Ovarian stimulation with hMG was initiated after the patient experienced withdrawal uterine bleeding, a baseline sonogram revealed no follicular cyst greater than 10 mm in diameter, and the serum E2 level was less than 50 pg/ml. The daily LA dose was then decreased to 0.25 mg/day. The hMG dose was individualized based on the patients age (greater than 40 of less than 40), day 3 FSH level (greater than 15 or less than 15 mIU/ml), and previous stimulation history; but the day 3 E2 level did not influence the ovarian stimulation protocol. Follicular maturation was triggered with hCG; 10,000 IU were administered when at least two follicles measured greater than 16 mm using a 5-MHz vaginal probe at a 40-mm focus. Transvaginal follicle aspiration was performed 35.5 hours after hCG administration. Luteal support was provided by P vaginal suppositories (300 mg twice daily) and hCG (3300 IU) given I.M. on days 3, 6, and 9 after retrieval. Transvaginal sonographic documentation of fetal viability was performed in all patients with a rising beta-hCG titer. Clinical pregnancy was defined as the presence of an intrauterine gestational sac documented by transvaginal sonography. The following parameters were evaluated: age, day 3 FSH and E2 concentrations, number of hMG ampules used, maximum E2 levels, cancellation rates, and clinical PR.
Two hundred seven patients with day 3 E2 concentrations less than 80 pg/ml underwent 265 cycles, whereas 27 cycles were initiated in 18 patients who had had a day 3 E2 greater or equal to 80 pg/ml. Cycles in which patients had had a day 3 E2 less than 80 pg/ml resulted in a clinical PR per initiated cycle of 37.0 percent, whereas those with E2 greater or equal to 80 pg/ml had a 14.8 percent clinical PR per initiated cycle. The clinical PR per ET were 37.1 percent and 18.2 percent, respectively. Cycles in patients with a day 3 E2 greater or equal to 80 pg/ml had a significantly higher cancellation rate due to poor ovarian stimulation compared with those with E2 less than 80 pg/ml. These higher cancellation rates and lower PR in patients with E2 greater or equal to 80 pg/ml occurred despite a statistically significant lower mean day 3 FSH compared with the day 3 FSH concentration in patients with E2 less than 80 pg/ml. There was no difference in age, number of ampules of hMG required, and peak E2 concentrations at the time of hCG administration between the two groups. When the analysis was restricted to the 279 initiated IVF cycles in patients with day 3 FSH levels less than 15 mIU/ml, the results were the same.
