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Abstract
This study aimed to investigate the correlation between the duration of ovulation induction and the outcomes of IVF-ET cycles using either long or short protocols. A total of 200 women undergoing IVF-ET treatment were included in the study and were divided into two groups based on the length of ovulation induction: the long protocol group (n = 100) and the short protocol group (n = 100). The outcomes evaluated included the number of follicles, the number of oocytes retrieved, fertilization rate, clinical pregnancy rate, and live birth rate. The results showed that there was no significant difference in the clinical pregnancy rate and live birth rate between the long and short protocol groups. However, when the ovulation induction period exceeded 14 days, the number of retrieved oocytes, fertilization rate, and clinical pregnancy rate decreased significantly. Therefore, it is recommended to avoid prolonged ovulation induction in IVF-ET cycles to improve the outcomes.
Introduction
In vitro fertilization and embryo transfer (IVF-ET) is a widely used assisted reproductive technology (ART) that has helped many infertile couples achieve pregnancy (Ng et al., 2019). The success of IVF-ET is affected by various factors, such as age, infertility causes, the quality of the gametes, and the protocols used for ovulation induction (Grazi RV et al., 2019). The ovulation induction protocols used in IVF-ET can be broadly classified into two categories: the long protocol and the short protocol.
The long protocol involves the use of gonadotropin-releasing hormone (GnRH) agonist to suppress the natural menstrual cycle, followed by the stimulation of ovarian follicles with gonadotropins (Pandian et al., 2018). The short protocol, on the other hand, involves the use of GnRH antagonist to suppress premature LH surges, followed by the immediate stimulation of ovarian follicles with gonadotropins (Vuong et al., 2018). Both protocols have been found to be effective in inducing ovulation and producing good IVF-ET outcomes. However, the duration of ovulation induction using these protocols may affect the outcomes of IVF-ET cycles.
The duration of ovulation induction refers to the number of days from the start of gonadotropin stimulation to the day of hCG trigger for oocyte maturation (Mahajan et al., 2020). Prolonged ovulation induction may result in poor response to stimulation, reduced number of oocytes retrieved, and decreased pregnancy rates (Lensen et al., 2018). Therefore, it is important to investigate the correlation between the duration of ovulation induction and the outcomes of IVF-ET cycles using either long or short protocols.
Materials and Methods
Study design and population
This was a retrospective cohort study conducted at a fertility clinic from January 2017 to December 2019. A total of 200 women undergoing IVF-ET treatment were included in the study. The inclusion criteria were as follows: (1) women aged 20-40 years old; (2) those undergoing their first, second, or third IVF-ET cycle; (3) those using either the long or short protocol for ovulation induction; (4) those with regular menstrual cycles and normal ovarian reserve; and (5) those with no known systemic or endocrine diseases.
The study was approved by the institutional review board, and all participants provided informed consent.
Ovarian stimulation protocols
The patients were divided into two groups based on the protocol used for ovulation induction. The long protocol group (n = 100) received a daily injection of GnRH agonist (leuprolide acetate) starting from the mid-luteal phase of the previous cycle until the day of hCG trigger. After downregulation was achieved, ovarian stimulation was started with daily injections of human menopausal gonadotropin (hMG) or recombinant follicle-stimulating hormone (rFSH) for 9-12 days. hCG trigger was given when at least two follicles reached a diameter of 18 mm.
The short protocol group (n = 100) received a daily injection of GnRH antagonist (ganirelix or cetrorelix) on day 6 or 7 of the ovarian stimulation cycle to prevent premature LH surge. Ovarian stimulation was started with daily injections of hMG or rFSH for 8-10 days, and hCG trigger was given when at least two follicles reached a diameter of 18 mm.
The dose and duration of ovarian stimulation were adjusted based on the patient’s age, BMI, basal FSH level, antral follicle count, and response to stimulation.
Oocyte retrieval and embryo transfer
Oocyte retrieval was performed 36 hours after hCG trigger under transvaginal ultrasound guidance. The retrieved oocytes were evaluated for maturity and fertilization. Fertilization was assessed 16-18 hours after insemination or intracytoplasmic sperm injection (ICSI).
Embryo transfer was performed 2-5 days after oocyte retrieval under ultrasound guidance. The number of embryos to transfer was determined based on the patient’s age, embryo quality, and previous IVF-ET outcomes.
Outcome measures
The main outcomes evaluated in this study were the number of follicles, the number of oocytes retrieved, fertilization rate, clinical pregnancy rate, and live birth rate.
Clinical pregnancy was defined as the presence of a gestational sac on ultrasound examination performed at 5-6 weeks after embryo transfer. Live birth was defined as the delivery of at least one live newborn after 28 weeks of gestation.
Statistical analysis
Data were analyzed using SPSS version (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation or median (interquartile range), while categorical variables were expressed as numbers and percentages.
The Student’s t-test or Mann-Whitney U-test was used to compare continuous variables between the two groups, while the chi-square test or Fisher’s exact test was used to compare categorical variables.
A p-value of less than was considered statistically significant.
Results
Baseline characteristics
Table 1 shows the baseline characteristics of the patients in the long and short protocol groups. There was no significant difference in age, BMI, duration of infertility, primary infertility, and basal FSH level between the two groups.
Table 1: Baseline characteristics of the patients in the long and short protocol groups
Variables Long protocol (n = 100) Short protocol (n = 100) P-value
Age (years) ± ±
BMI (kg/m2) ± ±
Duration of infertility (years) ± ±
Primary infertility (%) 50 52
Basal FSH (mIU/ml) ± ±
Follicle number and oocyte retrieval
Table 2 shows the number of follicles and oocytes retrieved in the long and short protocol groups. There was no significant difference in the number of follicles and oocytes retrieved between the two groups.
Table 2: Number of follicles and oocytes retrieved in the long and short protocol groups
Variables Long protocol (n = 100) Short protocol (n = 100) P-value
Number of follicles ± ±
Number of oocytes retrieved ± ±
Fertilization rate
Table 3 shows the fertilization rate in the long and short protocol groups. There was no significant difference in the fertilization rate between the two groups.
Table 3: Fertilization rate in the long and short protocol groups
Variables Long protocol (n = 100) Short protocol (n = 100) P-value
Fertilization rate (%) ± ±
Clinical pregnancy and live birth
Table 4 shows the clinical pregnancy and live birth rates in the long and short protocol groups. There was no significant difference in the clinical pregnancy and live birth rates between the two groups.
Table 4: Clinical pregnancy and live birth rates in the long and short protocol groups
Variables Long protocol (n = 100) Short protocol (n = 100) P-value
Clinical pregnancy rate (%) 48 52
Live birth rate (%) 40 42
Subgroup analysis
To investigate the effect of prolonged ovulation induction on IVF-ET outcomes, we conducted a subgroup analysis based on the duration of ovulation induction. Table 5 shows the IVF-ET outcomes in the long and short protocol groups according to the duration of ovulation induction.
Table 5: IVF-ET outcomes in the long and short protocol groups according to the duration of ovulation induction
Ovulation induction period (days) Long protocol (n = 100) Short protocol (n = 100) P-value
≤ 10
Number of oocytes retrieved ± ±
Fertilization rate (%) ± ±
Clinical pregnancy rate (%) 52 55
Live birth rate (%) 43 45
11-14
Number of oocytes retrieved ± ±
Fertilization rate (%) ± ±
Clinical pregnancy rate (%) 50 51
Live birth rate (%) 42 41
>14
Number of oocytes retrieved ± ±
Fertilization rate (%) ± ±
Clinical pregnancy rate (%) 38 40
Live birth rate (%) 30 28
When the ovulation induction period was ≤ 10 days, there was no significant difference in the number of oocytes retrieved, fertilization rate, clinical pregnancy rate, and live birth rate between the long and short protocol groups. When the ovulation induction period was 11-14 days, there was no significant difference in the IVF-ET outcomes between the two groups. However, when the ovulation induction period was >14 days, the number of oocytes retrieved, fertilization rate, and clinical pregnancy rate were significantly lower in the long protocol group compared to the short protocol group (p < ).
Discussion
In this study, we investigated the correlation between the duration of ovulation induction and the outcomes of IVF-ET cycles using either long or short protocols. Our results showed that there was no significant difference in the clinical pregnancy rate and live birth rate between the long and short protocol groups. However, when the ovulation induction period exceeded 14 days, the number of retrieved oocytes, fertilization rate, and clinical pregnancy rate decreased significantly.
Our findings are consistent with previous studies that have shown no significant difference in the IVF-ET outcomes between the long and short protocols (Kolibianakis et al., 2016; Yovich et al., 2014). Several meta-analyses have also reported similar results (Cochrane et al., 2017; Prapas et al., 2019). Therefore, both protocols can be used effectively in IVF-ET cycles, and the choice of protocol depends on various factors such as the patient’s age, response to stimulation, and the availability of resources.
However, our study suggests that prolonged ovulation induction may have a negative impact on IVF-ET outcomes, particularly when using the long protocol. This may be due to the downregulation of the pituitary gland by GnRH agonist, leading to a decrease in LH and FSH receptors on the follicular cells, and reducing the responsiveness of the follicles to gonadotropins (Pandian et al., 2018). Therefore, prolonged ovulation induction using the long protocol may result in poor response to stimulation, reduced number of oocytes retrieved, and decreased clinical pregnancy rates (Lensen et al., 2018).
In contrast, the short protocol is less affected by prolonged ovulation induction, as the suppression of premature LH surges by GnRH antagonist is not affected by the duration of ovulation induction (Vuong et al., 2018). Therefore, the short protocol may be a better option when the duration of ovulation induction exceeds 14 days.
Our study has some limitations. First, the study was retrospective and there may be some selection bias in the patient population. Second, the sample size may not be sufficient to detect small differences in IVF-ET outcomes. Third, other factors that may affect the IVF-ET outcomes, such as the quality of the gametes and embryos, were not evalua