| Part I Analysis of the causes of using freeze-all strategy in GnRHant protocol【OBJECTIVE】This research retrospective analyzed the causes of freeze-all in Gonadotropin releasing-hormone antagonist(GnRHant)protocol in assisted reproductive technology,in order to provide information for the clinical application of GnRHant protocol in infertility treatment.[METHODS]1097 cases of in vitro fertilization(IVF)or intracytoplasmic sperm injection(ICSI)cycles using GnRHant protocol in our centre from October 1,2014 to April 30,2017 were included,all of them result in a blockage of fresh embryo transfer(fET)and application of freeze-all strategy.799 cases of GnRHa protocol in the same period were chosen as a control group.All cases were grouped according to different reasons for fET cancellation,ovarian responsibility,female age and trigger types.Analyze the characteristic of the two protocols and the cause of cancellation of fET.[RESULTS]1.Endometrial factor and progesterone elevation(PE)were the most common reason for using freeze-all strategy in GnRHant protocol,while that of GnRHa protocol was prevention of ovarian hyperstimulation syndrome(OHSS).2.The proportion of OHSS prevention was lower in GnRHant protocol compared to GnRHa protocol(17.3%vs.43.8%,P<0.001),with the incidence of moderate and severe OHSS was lower as well(0.46%vs.1.38%,P=0.030).And the incidence of moderate and severe OHSS in cases using hCG trigger was 0.8%,while GnRHa+hCG trigger cycles was 0.3%,and no OHSS was happened in cases using GnRHa trigger repeatly.3.Compared to GnRHa protocol,the proportion of endometrial factor for cancellation was higher in GnRHant protocol(20.2%vs.8.3%,P<0.001).Besides,the proportion of PE was higher as well(15.3%vs.6.9%,P<0.001),while uterine cavity factor,personal factor,systematic factor,embryonic factor and comprehensive factor showed no significant differences between two protocols.4.The main reason for cancellation in hyperresponders was prevention of OHSS(45.1%),and the proportion was lower in GnRHant protocol(32.1%vs.58.1%,P<0.001).The most common reason in poor responders was embryonic factors(55.8%).5.As the age increases,the proportion of OHSS-prevention gradually decreased(52.5%vs..33.5%vs.21.6%vs.5.6%),while embryonic factor(4.3%vs.10.0%vs.15.5%vs.27.5%)gradually increased,and the differences were all significant(P<0.001).Compared to GnRHa protocol,the proportion of OHSS-prevention was lower in GnRHant protocol both in age under 30 and age 31-34,while PE and endometrial factor were higher.But the proportion of cancellation reasons showed no significant difference in age 35-39 and age over 40.[CONCLUSIONS]1.The most common reason for using freeze-all strategy in GnRHant protocol were endometrial factor and PE,probolily related to the influence of GnRHant to endometrial and the timing of trigger;while prevention of OHSS was the most common reasons in GnRHa protocol,for trigger with hCG was the only choice.2.GnRHant protocol,especially repeated GnRHa trigger cycles,may reduce or even eliminate the risk of severe OHSS effectively,which is iatrogenic and lethal potentially,while trigger with GnRHa+hCG still have a chance to develop severe OHSS.Thus we recommended GnRHant protocol trigger with GnRHa to prevent OHSS in hyperresponders,instead of using hCG.3.Regardless of protocols,with the increase of age and decrease of ovarian responsibility,the proportion of embryonic factors and uterine cavity factor tends to increase,while OHSS-prevention tends to decrease instead.3.Regardless of protocols,when fators damaged endometrial receptivity such as abnormal uterine cavity factor or PE in trigger day exist in the cycles,freeze-all strategy is recommended,in order to treat these fators properly with sufficient time and attain a satisfied pregnancy outcome.Prat II Analysis of the clinical outcome of subsequent FET in GnRHant protocol with freeze-all strategy【OBJECTIVE】Analyze the relationship between cancel reason and clinical outcomes of the subsequent freeze-thaw embryo transfer(FET)cycles in GnRHant protocol using freeze-all strategy,discuss factors influencing pregnancy outcome.[METHODS]Included 946 IVF/ICSI cycles using GnRHant protocol and cryopreserved all embryo in our centre from October 1,2014 to April 30,2017,and proceed FET cycles before October 1,2017,chose 692 GnRHa cycles in the same period as a control group.All cases were grouped according to different reasons for fET cancellation,female age,endometrial preparation protocol and endometrial thickness.We pay attention to the comparative analysis of the implantation rate,pregnancy rate,multiple pregnancy rate,early abortion rate,and live birth rate in the subsequent FET cycles.[RESULTS]1.Without consideration of female age(32.01 ± 5.06 vs.30.37±4.31,P<0.001),the pregnancy rate(57.1%vs.64.7%),embryo implantation rate(39.4%vs.45.9%),and multiple pregnancy rate(35.6%vs..40.0%)of GnRHant protocol were lower than those in GnRHa protocol in FET cycles,while early abortion rate(14.2%vs.9.7%)was higher,and the differences were all significant.By age stratification,the average age of GnRHant protocol was still slightly older than GnRHa protocol(32.51±1.09 vs.32.27 ± 1.09,P=0.022)and the proportion of diminished ovarian reserve patient(DOR)was higher(13.1%vs.4.3%,P=0.022)within age of 31-34,with a lower pregnancy rate(56.2%vs.67.9%),implataion rate(39.2%vs.49.2%),live birth rate(26.1%vs.37.0%)and cumulative pregnancy rate(72.2%vs.83.8%),which showed significant differences(P<0.05).The DOR proportion in age under 30 was higer(3.5%vs.1.6%,P=0.046),and cumulative pregnancy rate was lower(83.1%vs.88.4%,P=0.037),but silghtly differences in pregnancy rate,implation rate and live birth rate without significant.And there was no significant difference between two protocol in the above indicators among the other age groups.2.OHSS-prevention group,OHSS-prevention combine PE group and the OHSS-prevention combine uterine cavity group showed no significant difference on female age,AFC,Gn dosage,the number of oocyte retrived and 2PN,as well as pregnancy rate,implantation rate,live birth rate.Compared to OHSS prevention group,the PE group,endometrial group,individual factor group,systemic factor group,and PE combin uterine cavity group showed higher age and Gn dosage,lower AFC and retrived oocyte number with significant differences,but a lower implantation rate,pregnancy rate,live birth rate without significant differences.While uterine cavity group shows both similar tendency and significant differences among the above indicator when compared to OHSS-prevention group.3.Female age,the number of available embryos and DOR were embedded in logistic regression analysis curve,while bFSH,BMI,the number of oocytes retrieved,endometrial thickness,as well COS protocol,preparation protocol and cause of cryopreservation were nonsignificant.[CONCLUSIONS]1.GnRHant protocol is more simplified,flexible,less visit frequency and medication,meanwhile a satisfactory FET outcome compared with GnRHa protocol,and it is worth to extend clinically.2.Freeze-all strategy would be the first choice for woman with high risk of OHSS since it decreases the possibility of arising of OHSS,meanwhile obtain a satisfactory outcomes.The incidence of PE is higer in GnRHant protocol,but shows a good pregnancy outcome in FET cycles.For patient with uterine diseases,unsatisfied clinical outcome may relating to abnormal uterine cavity,and a positive treatment may be an important method to improve it.3.Regardless of protocol,age is an important factor influencing pregnancy outcomes.As the age increases,the clinical pregnancy rate drops and earlymiscarriage rate rises.4.Female age increase and DOR are the reasons for lower pregnancy rate in FET cycles of GnRHant protocol using freeze-all strategy.,related to embryo quality and the decrease of number of available embryos caused by DOR. |
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