الفهرس 
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Abstract
OHSS is a severe complication of gonadotrophin treatment in infertile women subjected to ART cycles. The severe form may occur in 0.1–3% of all cycles.
Coasting is a strategy for the prevention of severe OHSS during ovarian stimulation. The word is taken from nautical terminology; after reaching land under full power or full sail, a boat slowly approaches and follows the coast without any additional effort, taking advantage of the energy expended previously. It involves withdrawing exogenous gonadotrophins and postponing hCG administration until the patient’s serum E2 level decreases to a `safer’ level.
GnRH antagonist administration causes an immediate suppression of E2 levels and therefore could prevent OHSS in GnRH agonist cycles.
The aim of this work is to study the value of GnRH antagonist administration as an alternative to coasting in prevention of severe OHSS and its impact on embryos quality& the outcome in women undergoing ICSI.
This study was conducted during the period from January 2013 to June 2014. at the Assisted Reproduction Technology Unit, International Islamic Centre for Population Studies & Research, Al-Azhar University and included 300 women seeking fertility.
Inclusion criteria:
During the course of ovarian stimulation, women were considered at high risk of developing OHSS if they have a large number of follicles (>20) on both ovaries, with 90% of the follicles being small (<14 mm in mean diameter), and E2 concentration ≥ 3500 pg/ml. These women were included in the study.
Women included in the study were divided into 2 groups:
group (A): including 150 patients who were undergone coasting. E2 was measured daily until the concentration falls to ≤ 3000 pg/ml.
group (B): including 150 patients who received GnRH antagonist (Cetrorelix acetate 0.25 mg) daily by subcutaneous injection until day of hCG administration. Gonadotrophins and GnRH agonist was discontinued with the start of antagonist administration. E2 was measured daily until the concentration falls to ≤ 3000 pg/ml.
HCG was administered when E2 concentration levels fell to < 3000 pg/ml in both groups. Oocytes were retrieved at 36 hours after hCG injection and subjected to ICSI. ET was usually performed 3 days after occyte collection.
LPS was given to all patients. Prontogest IM injection was given. Pregnancy test was done 14 days after ET and if was positive, prontogest was continued until 8 weeks gestation. Pregnancy was confirmed at 5-6 weeks gestation by visualization of a viable fetus by U/S examination.
• Results:
There was no significant difference in patients’ characteristics as age, type and duration of infertility, BMI, and PCO between the two groups. There was no significant difference in basal hormonal profile between the two groups. There was no significant difference in the mean number of HMG injections, the number of days of stimulation, the E2 concentration on day of starting intervention, and the E2 concentration on day of hCG administration were not significantly different between the two groups.
The mean number of oocytes retrieved in the antagonist arm was significantly higher than in the coasting arm (8.2±3.1versus 6.7±3.2, P-value 0.001). The mean number of MII oocytes retrieved in the antagonist arm was significantly higher than in the coasting arm (4.7±2.3versus 3.7±2.0, P-value 0.001). The mean number of fertilized oocytes in the antagonist arm was significantly higher than in the coasting arm (8.2±3.1versus 2.9±1.8, P-value 0.001). The mean number of high quality embryos in the antagonist arm was significantly higher than in the coasting arm (2.3±1.2 versus 1.6±0.7, P-value 0.001). The mean number of embryos transferred was significantly higher in the antagonist arm than in the coasting arm (2.1±0.8 versus 1.9±0.8, P-value 0.042). There were significantly more days of coasting (2.9±1.4) as compared with days of antagonist (2.2±1.1, P-value 0.001). The mean number of GnRH antagonist injections administrated was 2.2±1.1.
There was no significant difference in the clinical pregnancy and multiple pregnancy rates between the groups. No women developed early severe OHSS in either group but 2 women developed late severe OHSS in each group without significant difference.
In group B, the mean E2 concentration dropped after 24 h of antagonist administration and continued to DROP with administration of more antagonist injections until hCG administration. In the coasting group, there was an initial rise in E2 concentration in the first 24 h of coasting. Afterwards, the DROP in E2 concentration continued until the day of hCG administration.
Coasting 1-2 days as compared with antagonist 1-2 days showed a significantly more high quality embryos (P value =0.001) and a significantly shorter duration of intervention (P value = 0.024) in the antagonist arm. In the coasting group, the mean number of embryos grade 2 was significantly higher in women coasted for 3 days or less as compared with 4 days or more. The mean number of embryos grade 1 was higher in women coasted for 3 days or less as compared with 4 days or more but no significant difference.
CONCLUSION
Several conclusions can be reached from this study:
1. Coasting and coasting with GnRH antagonist are effective methods for prevention of OHSS.
2. GnRH antagonist was superior to coasting in producing significantly more oocytes and more high quality embryos as well as reducing the time until hCG administration. There was no significant difference in PR between the two groups. No OHSS developed in either group.
RECOMMENDATION
1. GnRH antagonist administration during coasting is a valuable alternative for prevention of OHSS during COH.
2. Larger randomized studies comparing coasting with or without GnRH antagonist are required to determine whether there is any difference in PR and the incidence of OHSS between the two protocols.